View source for Vagina

{{Short description|Part of the female reproductive tract}}
{{About|the birth canal|the external female genitals|vulva|other uses|Vagina (disambiguation)}}
<noinclude>{{split|Human Vagina|date=November 2024|discuss=Talk:Vagina#Split request}}</noinclude>{{Good article}}
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{{Use mdy dates|date=August 2020}}
{{Infobox anatomy
| Name        = Vagina
| Latin       = vagina
| Image       = Vaginal Canal Normal vs. Menopause.png
| Caption     = Normal adult human vagina, before (left) and after (right) menopause
| Width       = 200
| Image2      = Scheme_female_reproductive_system-en.svg
| Caption2    = Diagram of the female human reproductive tract and ovaries
| Precursor   = [[Urogenital sinus]] and [[paramesonephric duct]]s
| System      =
| Artery      = Superior part to [[uterine artery]], middle and inferior parts to [[vaginal artery]]
| Vein        = Uterovaginal venous plexus, [[vaginal vein]]
| Nerve       = {{Unbulleted list|Sympathetic: lumbar splanchnic plexus|Parasympathetic: pelvic splanchnic plexus}}
| Lymph       = Upper part to [[internal iliac lymph nodes]], lower part to [[superficial inguinal lymph nodes]]
}}
In [[mammal]]s and other animals, the '''vagina''' ({{plural form}}: '''vaginas''' or '''vaginae''')<ref name="Stevenson">{{cite book|vauthors=Stevenson A|title=Oxford Dictionary of English|publisher=[[Oxford University Press]]|isbn=978-0-19-957112-3|year=2010|page=1962|url=https://books.google.com/books?id=anecAQAAQBAJ&pg=PA1962|access-date=October 27, 2015|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161739/https://books.google.com/books?id=anecAQAAQBAJ&pg=PA1962|url-status=live}}</ref> is the elastic, muscular [[sex organ|reproductive organ]] of the female [[genital tract]]. In humans, it extends from the [[vulval vestibule]] to the [[cervix]] (neck of the [[uterus]]). The [[#Vaginal opening and hymen|vaginal introitus]] is normally partly covered by a thin layer of [[mucous membrane|mucosal tissue]] called the [[hymen]]. The vagina allows for [[Copulation (zoology)|copulation]] and [[birth]].<!-- NOTE: "Birth" instead of "childbirth." The article is not solely about humans. "Childbirth" is mentioned lower.-->  It also channels [[Menstruation (mammal)|menstrual flow]], which occurs in humans and closely related [[primate]]s as part of the [[menstrual cycle]].
To accommodate smoother penetration of the vagina during sexual intercourse or other [[sexual activity]], vaginal moisture increases during [[sexual arousal]] in human females and other female mammals. This increase in moisture provides [[vaginal lubrication]], which reduces friction. The texture of the vaginal walls creates friction for the [[penis]] during sexual intercourse and stimulates it toward [[ejaculation]], enabling [[fertilization]]. Along with pleasure and bonding, women's sexual behavior with other people can result in [[Sexually transmitted disease|sexually transmitted infections]] (STIs), the risk of which can be reduced by recommended [[safe sex]] practices. [[#Infections, diseases, and safe sex|Other health issues]] may also affect the human vagina.
The vagina has evoked strong reactions in societies throughout history, including negative perceptions and language, cultural [[taboo]]s, and their use as symbols for [[female sexuality]], spirituality, or regeneration of life. In [[Colloquialism|common speech]], the word ''vagina'' is often used incorrectly to refer to the vulva or to the female genitals in general.
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==Etymology and definition==
The term ''vagina'' is from [[Latin]] ''vāgīna'', meaning "sheath" or "[[scabbard]]".<ref name="Stevenson">{{cite book|vauthors=Stevenson A|title=Oxford Dictionary of English|publisher=[[Oxford University Press]]|isbn=978-0-19-957112-3|year=2010|page=1962|url=https://books.google.com/books?id=anecAQAAQBAJ&pg=PA1962|access-date=October 27, 2015|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161739/https://books.google.com/books?id=anecAQAAQBAJ&pg=PA1962|url-status=live}}</ref> The vagina may also be referred to as the '''birth canal''' in the context of [[pregnancy]] and [[childbirth]].<ref name="Nevid">{{cite book|vauthors=Nevid J, Rathus S, Rubenstein H|title=Health in the New Millennium: The Smart Electronic Edition (S.E.E.)|publisher=[[Macmillan Publishers|Macmillan]]|isbn=978-1-57259-171-4|year=1998|page=297|url=https://books.google.com/books?id=H65N8vmbgTYC&pg=PA297|access-date=October 27, 2015|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161746/https://books.google.com/books?id=H65N8vmbgTYC&pg=PA297|url-status=live}}</ref><ref name="Lipsky">{{cite book|vauthors=Lipsky MS|title=American Medical Association Concise Medical Encyclopedia|publisher=[[Random House Reference]]|isbn=978-0-375-72180-9|year=2006|page=96|url=https://books.google.com/books?id=DtZ_XdSymSIC&pg=PA96|access-date=October 27, 2015|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161740/https://books.google.com/books?id=DtZ_XdSymSIC&pg=PA96|url-status=live}}</ref> Although by its dictionary and anatomical definitions, the term ''vagina'' refers exclusively to the specific internal structure, it is [[Colloquialism|colloquially]] used to refer to the [[vulva]] or to both the vagina and vulva.<ref name="Dalton">{{cite book|vauthors=Dalton M|title=Forensic Gynaecology|publisher=[[Cambridge University Press]]|isbn=978-1-107-06429-4|year=2014|page=65|url=https://books.google.com/books?id=Kr6ZBAAAQBAJ&pg=PA65|access-date=October 27, 2015|archive-date=September 17, 2020|archive-url=https://web.archive.org/web/20200917163313/https://books.google.com/books?id=Kr6ZBAAAQBAJ&pg=PA65|url-status=live}}</ref><ref name="Jones">{{cite book|vauthors=Jones T, Wear D, Friedman LD|title=Health Humanities Reader|publisher=[[Rutgers University Press]]|isbn=978-0-8135-7367-0|year=2014|pages=231–232|url=https://books.google.com/books?id=wqRvBAAAQBAJ&pg=PT231|access-date=October 27, 2015|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161741/https://books.google.com/books?id=wqRvBAAAQBAJ&pg=PT231|url-status=live}}</ref>
Using the term ''vagina'' to mean "vulva" can pose medical or legal confusion; for example, a person's interpretation of its location might not match another's interpretation of the location.<ref name="Dalton"/><ref name="Kirkpatrick">{{cite book|vauthors=Kirkpatrick M|title=Human Sexuality: Personality and Social Psychological Perspectives|publisher=[[Springer Science & Business Media]]|isbn=978-1-4684-3656-3|year=2012|page=175|url=https://books.google.com/books?id=qfsxBwAAQBAJ&pg=PA175|access-date=February 3, 2016|archive-date=April 22, 2021|archive-url=https://web.archive.org/web/20210422221613/https://books.google.com/books?id=qfsxBwAAQBAJ&pg=PA175|url-status=live}}</ref> Medically, one description of the vagina is that it is the canal between the [[hymen]] (or remnants of the hymen) and the [[cervix]], while a legal description is that it begins at the vulva (between the [[labia]]).<ref name="Dalton"/> It may be that the incorrect use of the term ''vagina'' is due to not as much thought going into the anatomy of the female genitals as has gone into the study of male genitals, and that this has contributed to an absence of correct vocabulary for the external female genitalia among both the general public and health professionals. Because a better understanding of female genitalia can help combat sexual and psychological harm with regard to female development, researchers endorse correct terminology for the vulva.<ref name="Kirkpatrick"/><ref name="Hill">{{cite book|vauthors=Hill CA|title=Human Sexuality: Personality and Social Psychological Perspectives|publisher=[[SAGE Publications]]|isbn=978-1-5063-2012-0|year=2007|pages=265–266|url=https://books.google.com/books?id=WUJsCgAAQBAJ&pg=PA266|quote=Little thought apparently has been devoted to the nature of female genitals in general, likely accounting for the reason that most people use incorrect terms when referring to female external genitals. The term typically used to talk about female genitals is ''vagina'', which is actually an internal sexual structure, the muscular passageway leading outside from the uterus. The correct term for the female external genitals is ''vulva'', as discussed in chapter 6, which includes the clitoris, labia majora, and labia minora.|access-date=February 3, 2016|archive-date=June 3, 2021|archive-url=https://web.archive.org/web/20210603161753/https://books.google.com/books?id=WUJsCgAAQBAJ&pg=PA266|url-status=live}}</ref><ref name="Sáenz-Herrero">{{cite book|vauthors=Sáenz-Herrero M|title=Psychopathology in Women: Incorporating Gender Perspective into Descriptive Psychopathology|publisher=[[Springer Publishing|Springer]]|isbn=978-3-319-05870-2|year=2014|page=250|url=https://books.google.com/books?id=-unSBAAAQBAJ&pg=PA250|quote=In addition, there is a current lack of appropriate vocabulary to refer to the external female genitals, using, for example, 'vagina' and 'vulva' as if they were synonyms, as if using these terms incorrectly were harmless to the sexual and psychological development of women.'|access-date=February 3, 2016|archive-date=April 22, 2021|archive-url=https://web.archive.org/web/20210422221614/https://books.google.com/books?id=-unSBAAAQBAJ&pg=PA250|url-status=live}}</ref>
==Structure==
===Gross anatomy===
{{See also|Vaginal support structures}}
[[File:Blausen 0400 FemaleReproSystem 02b.png|thumb|upright=1.36|alt=Diagram illustrating female pelvic anatomy|Pelvic anatomy including organs of the female reproductive system]]
The human vagina is an elastic, muscular canal that extends from the vulva to the cervix.<ref name="Snell">{{cite book|vauthors=Snell RS|title=Clinical Anatomy: An Illustrated Review with Questions and Explanations|url=https://books.google.com/books?id=5s7jDVQkCfoC&pg=PA98|year=2004|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-4316-7|page=98|access-date=October 27, 2015|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000538/https://books.google.com/books?id=5s7jDVQkCfoC&pg=PA98|url-status=live}}</ref><ref name="Dutta">{{cite book|vauthors=Dutta DC|title=DC Dutta's Textbook of Gynecology|year=2014|publisher=JP Medical Ltd|isbn=978-93-5152-068-9|pages=2–7|url=https://books.google.com/books?id=40yVAwAAQBAJ&pg=PA2|access-date=October 27, 2015|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043225/https://books.google.com/books?id=40yVAwAAQBAJ&pg=PA2|url-status=live}}</ref> The opening of the vagina lies in the [[urogenital triangle]]. The urogenital triangle is the front triangle of the [[perineum]] and also consists of the urethral opening and associated parts of the external genitalia.<ref name="Drake">{{cite book|vauthors=Drake R, Vogl AW, Mitchell A|title=Gray's Basic Anatomy E-Book|year=2016|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-50850-6|page=246|url=https://books.google.com/books?id=fojKDQAAQBAJ&pg=PA246|access-date=May 25, 2018|archive-date=June 4, 2021|archive-url=https://web.archive.org/web/20210604234718/https://books.google.com/books?id=fojKDQAAQBAJ&pg=PA246|url-status=live}}</ref> The '''vaginal canal''' travels upwards and backwards, between the urethra at the front, and the rectum at the back. Near the upper vagina, the cervix protrudes into the vagina on its front surface at approximately a 90 degree angle.<ref name="Mulhall">{{cite book |vauthors=Ginger VA, Yang CC |chapter=Functional Anatomy of the Female Sex Organs |veditors=Mulhall JP, Incrocci L, Goldstein I, Rosen R |title=Cancer and Sexual Health |isbn=978-1-60761-915-4 |publisher=[[Springer Publishing|Springer]] |year=2011 |pages=13, 20–21 |chapter-url=https://books.google.com/books?id=GpIadil3YsQC&pg=PA13 |access-date=August 20, 2020 |archive-date=December 16, 2019 |archive-url=https://web.archive.org/web/20191216021705/https://books.google.com/books?id=GpIadil3YsQC&pg=PA13 |url-status=live }}</ref> The vaginal and urethral openings are protected by the labia.<ref name="Kinetics2009">{{cite book|vauthors=Ransons A|chapter=Reproductive Choices|title=Health and Wellness for Life|chapter-url=https://books.google.com/books?id=2GZ7N4wOeGYC&pg=PA221|date=May 15, 2009|publisher=Human Kinetics 10%|isbn=978-0-7360-6850-5|page=221|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506004528/https://books.google.com/books?id=2GZ7N4wOeGYC&pg=PA221|url-status=live}}</ref>
When not [[sexually aroused]], the vagina is a collapsed tube, with the front and back walls placed together. The lateral walls, especially their middle area, are relatively more rigid. Because of this, the collapsed vagina has an H-shaped cross section.<ref name="Dutta"/><ref name="Beckmann 2">{{cite book|vauthors=Beckmann CR|title=Obstetrics and Gynecology|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-8807-6|page=37|year=2010|url=https://books.google.com/books?id=0flWgd3OJLEC&pg=PA37|quote=Because the vagina is collapsed, it appears H-shaped in cross section.|access-date=January 31, 2017|archive-date=February 15, 2017|archive-url=https://web.archive.org/web/20170215191755/https://books.google.com/books?id=0flWgd3OJLEC&pg=PA37|url-status=live}}</ref> Behind, the upper vagina is separated from the [[rectum]] by the [[recto-uterine pouch]], the middle vagina by loose [[connective tissue]], and the lower vagina by the [[Perineum#Body|perineal body]].<ref name=GRAYS2008>{{cite book |veditors=Standring S, Borley NR |title=Gray's anatomy : the anatomical basis of clinical practice|date=2008|publisher=Churchill Livingstone|location=London|isbn=978-0-8089-2371-8|edition=40th|pages=1281–4}}</ref> Where the vaginal [[Lumen (anatomy)|lumen]] surrounds the cervix of the uterus, it is divided into four continuous regions ([[vaginal fornices]]); these are the anterior, posterior, right lateral, and left lateral fornices.<ref name="Snell"/><ref name="Dutta"/> The posterior fornix is deeper than the anterior fornix.<ref name="Dutta"/>
Supporting the vagina are its upper, middle, and lower third muscles and ligaments. The upper third are the [[levator ani]] muscles, and the transcervical, [[Pubocervical ligament|pubocervical]], and sacrocervical ligaments.<ref name="Snell"/><ref name="Baggish">{{cite book|vauthors=Baggish MS, Karram MM|title=Atlas of Pelvic Anatomy and Gynecologic Surgery - E-Book|year=2011|page=582|publisher=[[Elsevier Health Sciences]]|isbn=978-1-4557-1068-3|url=https://books.google.com/books?id=lwWldKFVPYYC&pg=PA582|access-date=May 7, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043154/https://books.google.com/books?id=lwWldKFVPYYC&pg=PA582|url-status=live}}</ref> It is supported by the upper portions of the [[cardinal ligament]]s and the [[parametrium]].<ref name="Arulkumaran 1">{{cite book|vauthors=Arulkumaran S, Regan L, Papageorghiou A, Monga A, Farquharson D|title=Oxford Desk Reference: Obstetrics and Gynaecology|year=2011|page=472|publisher=[[OUP Oxford]]|isbn=978-0-19-162087-4|url=https://books.google.com/books?id=lRaWcRYx_7YC&pg=PA472|access-date=May 7, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703220025/https://books.google.com/books?id=lRaWcRYx_7YC&pg=PA472|url-status=live}}</ref> The middle third of the vagina involves the [[urogenital diaphragm]].<ref name="Snell"/> It is supported by the levator ani muscles and the lower portion of the cardinal ligaments.<ref name="Arulkumaran 1"/> The lower third is supported by the perineal body,<ref name="Snell"/><ref name="Elsevier Obstetrics">{{Cite book |title=Manual of Obstetrics |edition =3rd |publisher=[[Elsevier]] |year=2011 |pages=1–16 |isbn=978-81-312-2556-1}}</ref> or the urogenital and [[pelvic diaphragm]]s.<ref name="Smith 2">{{cite book|vauthors=Smith RP, Turek P|title=Netter Collection of Medical Illustrations: Reproductive System E-Book|year=2011|page=443|publisher=[[Elsevier Health Sciences]]|isbn=978-1-4377-3648-9|url=https://books.google.com/books?id=ySriOOirL_UC&pg=PT443|access-date=May 7, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211240/https://books.google.com/books?id=ySriOOirL_UC&pg=PT443|url-status=live}}</ref> The lower third may also be described as being supported by the perineal body and the pubovaginal part of the levator ani muscle.<ref name="Baggish"/>
====Vaginal opening and hymen====
[[File:Vaginal opening description-en.svg|A human vulva with vaginal opening labeled|thumb]]
The '''vaginal opening''' (also known as the '''vaginal introitus''' and the Latin '''''ostium vaginae''''')<ref>{{cite book|last1=Ricci|first1=Susan Scott|last2=Kyle|first2=Terri|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|year = 2009|title=Maternity and Pediatric Nursing|page=77|access-date=January 7, 2024|isbn=978-0-78178-055-1|url=https://books.google.com/books?id=gaYtFuND7VIC&pg=PA77}}</ref><ref>{{cite book|last=Zink|first=Christopher|publisher=De Gruyter|year = 2011|title= Dictionary of Obstetrics and Gynecology |page=174|isbn= 978-3-11085-727-6 |url= https://books.google.com/books?id=EQlvzV9V7xIC&pg=PA174}}</ref> is at the posterior end of the [[vulval vestibule]], behind the [[urinary meatus|urethral opening]]. The term ''introitus'' is more technically correct than "opening", since the vagina is usually collapsed, with the opening closed. The opening to the vagina is normally obscured by the [[labia minora]] (inner lips), but may be exposed after [[vaginal delivery]].<ref name="Dutta"/>
====Variations and size====
{{Main|Human vaginal size}}
The length of the vagina [[anatomical variation|varies]] among women of child-bearing age. Because of the presence of the cervix in the front wall of the vagina, there is a difference in length between the front wall, approximately 7.5&nbsp;cm (2.5 to 3 in) long, and the back wall, approximately 9&nbsp;cm (3.5&nbsp;in) long.<ref name="Dutta"/><ref name="Wylie"/>  During sexual arousal, the vagina expands both in length and width. If a woman stands upright, the vaginal canal points in an upward-backward direction and forms an angle of approximately 45 degrees with the uterus.<ref name="Dutta"/><ref name="Elsevier Obstetrics"/> The vaginal opening and hymen also vary in size; in children, although the hymen commonly appears [[crescent]]-shaped, many shapes are possible.<ref name="Dutta"/><ref name="Emans">{{cite book|vauthors=Emans SJ|chapter=Physical Examination of the Child and Adolescent|title=Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas|edition=2nd|publisher=[[Oxford University Press]]|pages=61–65|isbn=978-0-19-974782-5|date=2000|chapter-url=https://books.google.com/books?id=3eQZhs4PwrYC|access-date=August 2, 2015|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044740/https://books.google.com/books?id=3eQZhs4PwrYC|url-status=live}}</ref>
===Development===
{{Further|Development of the reproductive system}}
[[File:Sobo 1906 508.png|right|thumb|alt=Drawn anatomic illustration as described in caption|An illustration showing a cut-away portion of the vagina and upper female genital tract (only one ovary and fallopian tube shown). Circular folds (also called rugae) of vaginal mucosa can be seen.]]
The vaginal plate is the precursor to the vagina.<ref name="Edmonds" /> During development, the vaginal plate begins to grow where the fused ends of the [[paramesonephric duct]]s (Müllerian ducts) enter the back wall of the [[urogenital sinus]] as the [[sinus tubercle]]. As the plate grows, it significantly separates the cervix and the urogenital sinus; eventually, the central cells of the plate break down to form the vaginal [[Lumen (anatomy)|lumen]].<ref name="Edmonds">{{cite book|vauthors=Edmonds K|title=Dewhurst's Textbook of Obstetrics and Gynaecology|publisher=[[John Wiley & Sons]]|isbn=978-0-470-65457-6|year=2012|page=423|url=https://books.google.com/books?id=HfakBRceodcC&pg=PA423|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506172501/https://books.google.com/books?id=HfakBRceodcC&pg=PA423|url-status=live}}</ref> This usually occurs by the twenty to twenty-fourth week of development. If the lumen does not form, or is incomplete, membranes known as [[vaginal septum|vaginal septa]] can form across or around the tract, causing obstruction of the outflow tract later in life.<ref name="Edmonds"/>
There are conflicting views on the embryologic origin of the vagina. The majority view is Koff's 1933 description, which posits that the upper two-thirds of the vagina originate from the caudal part of the Müllerian duct, while the lower part of the vagina develops from the urogenital sinus.<ref name="Herrington">{{cite book|vauthors=Herrington CS|title=Pathology of the Cervix|publisher=[[Springer Science & Business Media]]|isbn=978-3-319-51257-0|year=2017|pages=2–3|url=https://books.google.com/books?id=hc40DwAAQBAJ&pg=PA2|access-date=March 21, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211425/https://books.google.com/books?id=hc40DwAAQBAJ&pg=PA2|url-status=live}}</ref><ref name="Woodruff">{{cite book|vauthors=Woodruff TJ, Janssen SJ, Guillette LJ, Jr, Giudice LC|title=Environmental Impacts on Reproductive Health and Fertility|publisher=[[Cambridge University Press]]|isbn=978-1-139-48484-8|year=2010|page=33|url=https://books.google.com/books?id=WQRAfsjuUgQC&pg=PA33|access-date=March 21, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211348/https://books.google.com/books?id=WQRAfsjuUgQC&pg=PA33|url-status=live}}</ref> Other views are Bulmer's 1957 description that the vaginal epithelium derives solely from the urogenital sinus epithelium,<ref name="New insights"/> and Witschi's 1970 research, which reexamined Koff's description and concluded that the [[sinovaginal bulb]]s are the same as the lower portions of the [[Wolffian duct]]s.<ref name="Woodruff"/><ref name="Grigoris">{{cite book|vauthors=Grimbizis GF, Campo R, Tarlatzis BC, Gordts S|title=Female Genital Tract Congenital Malformations: Classification, Diagnosis and Management|publisher=[[Springer Science & Business Media]]|isbn=978-1-4471-5146-3|year=2015|page=8|url=https://books.google.com/books?id=IGlnBgAAQBAJ&pg=PA8|access-date=March 21, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211446/https://books.google.com/books?id=IGlnBgAAQBAJ&pg=PA8|url-status=live}}</ref> Witschi's view is supported by research by Acién et al., Bok and Drews.<ref name="Woodruff"/><ref name="Grigoris"/> Robboy et al. reviewed Koff and Bulmer's theories, and support Bulmer's description in light of their own research.<ref name="New insights"/> The debates stem from the complexity of the interrelated tissues and the absence of an animal model that matches human vaginal development.<ref name="New insights">{{cite journal |vauthors=Robboy S, Kurita T, Baskin L, Cunha GR |year=2017 |title=New insights into human female reproductive tract development |pmid=28918284|pmc=5712241 |journal=Differentiation |volume= 97|pages=9–22|doi=10.1016/j.diff.2017.08.002|issn=0301-4681 }}</ref><ref name="Kurman">{{cite book|vauthors=Kurman RJ|title=Blaustein's Pathology of the Female Genital Tract|publisher=[[Springer Science & Business Media]]|isbn=978-1-4757-3889-6|year=2013|page=132|url=https://books.google.com/books?id=sM3eBwAAQBAJ&pg=PA132|access-date=March 21, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043223/https://books.google.com/books?id=sM3eBwAAQBAJ&pg=PA132|url-status=live}}</ref> Because of this, study of human vaginal development is ongoing and may help resolve the conflicting data.<ref name="Woodruff"/>
===Microanatomy===
{{Main|Vaginal epithelium}}
[[File:Vagina (mucosa).JPG|thumb|alt=Micrograph of vaginal wall|Medium-power magnification [[micrograph]] of a [[H&E stain]]ed slide showing a portion of a vaginal wall. [[Stratified squamous epithelium]] and underling connective tissue can be seen. The deeper muscular layers are not shown. The black line points to a fold in the mucosa.]]
The '''vaginal wall''' from the lumen outwards consists firstly of a [[mucosa]] of [[stratified squamous epithelium]] that is not [[Stratified squamous epithelium#Keratinized|keratinized]], with a [[lamina propria]] (a thin layer of [[connective tissue]]) underneath it. Secondly, there is a layer of [[smooth muscle]] with bundles of circular fibers internal to longitudinal fibers (those that run lengthwise). Lastly, is an outer layer of connective tissue called the [[adventitia]]. Some texts list four layers by counting the two sublayers of the mucosa (epithelium and lamina propria) separately.<ref name="Brown">{{cite book|vauthors=Brown L|title=Pathology of the Vulva and Vagina|year=2012|publisher=[[Springer Science+Business Media]]|isbn=978-0-85729-757-0|pages=6–7|url=https://books.google.com/books?id=Yv2CMHoVR9wC&pg=PA6|access-date=October 27, 2015|archive-date=April 25, 2016|archive-url=https://web.archive.org/web/20160425014619/https://books.google.com/books?id=Yv2CMHoVR9wC&pg=PA6|url-status=live}}</ref><ref name="Arulkumaran">{{cite book|vauthors=Arulkumaran S, Regan L, Papageorghiou A, Monga A, Farquharson D|title=Oxford Desk Reference: Obstetrics and Gynaecology|year=2011|publisher=[[Oxford University Press]]|isbn=978-0-19-162087-4|page=471|url=https://books.google.com/books?id=lRaWcRYx_7YC&pg=PA471|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506160720/https://books.google.com/books?id=lRaWcRYx_7YC&pg=PA471|url-status=live}}</ref>
The smooth [[muscular layer]] within the vagina has a weak contractive force that can create some pressure in the lumen of the vagina; much stronger contractive force, such as during childbirth, comes from muscles in the [[pelvic floor]] that are attached to the adventitia around the vagina.<ref name=Bitzer>{{cite book|vauthors=Bitzer J, Lipshultz L, Pastuszak A, Goldstein A, Giraldi A, Perelman M |title=Management of Sexual Dysfunction in Men and Women |date=2016 |publisher=Springer New York |isbn=978-1-4939-3099-9 |page=202 |language=en |chapter=The Female Sexual Response: Anatomy and Physiology of Sexual Desire, Arousal, and Orgasm in Women|doi=10.1007/978-1-4939-3100-2_18 }}</ref>
The lamina propria is rich in blood vessels and lymphatic channels. The muscular layer is composed of smooth muscle fibers, with an outer layer of longitudinal muscle, an inner layer of circular muscle, and oblique muscle fibers between. The outer layer, the adventitia, is a thin dense layer of connective tissue and it blends with loose connective tissue containing blood vessels, [[lymphatic vessel]]s and nerve fibers that are between pelvic organs.<ref name="Mulhall" /><ref name="Arulkumaran" /><ref name="Wylie">{{cite book|vauthors=Wylie L|title=Essential Anatomy and Physiology in Maternity Care|year=2005|publisher=Elsevier Health Sciences|isbn=978-0-443-10041-3|pages=157–158|url=https://books.google.com/books?id=QgpOvSDxGGYC&pg=PA157|access-date=October 27, 2015|archive-date=May 5, 2016|archive-url=https://web.archive.org/web/20160505063932/https://books.google.com/books?id=QgpOvSDxGGYC&pg=PA157|url-status=live}}</ref> The vaginal mucosa is absent of glands. It forms folds (transverse ridges or [[rugae]]), which are more prominent in the outer third of the vagina; their function is to provide the vagina with increased surface area for extension and stretching.<ref name="Snell"/><ref name="Dutta"/>
[[File:Rugae vaginales.jpg|thumb|alt=Close-up photograph of vagina|Folds of mucosa (or [[vaginal rugae]]) are shown in the front third of a vagina.]]
The epithelium of the ectocervix (the portion the uterine cervix extending into the vagina) is an extension of, and shares a border with, the vaginal epithelium.<ref name="Junctions">{{cite journal|vauthors=Blaskewicz CD, Pudney J, Anderson DJ |title=Structure and function of intercellular junctions in human cervical and vaginal mucosal epithelia.|journal=Biology of Reproduction|date=July 2011|volume=85|issue=1|pages=97–104|doi=10.1095/biolreprod.110.090423|pmid=21471299|pmc=3123383}}</ref>  The vaginal epithelium is made up of layers of cells, including the [[Stratum basale|basal cells]], the parabasal cells, the superficial [[squamous cell|squamous flat cells]], and the intermediate cells.<ref name="Mayeaux">{{cite book|title=Modern Colposcopy Textbook and Atlas |vauthors=Mayeaux EJ, Cox JT |publisher=[[Lippincott Williams & Wilkins]]|year=2011|isbn=978-1-4511-5383-5|url=https://books.google.com/books?id=3lEtAxpNLewC&pg=SA2-PA29-IA2}}</ref> The basal layer of the epithelium is the most mitotically active and reproduces new cells.<ref name="Blaustein2002">{{cite book|url=https://books.google.com/books?id=tuKGMxGRKa8C|title=Blaustein's Pathology of the Female Genital Tract|publisher=Springer|year=2002|veditors=Kurman RJ|edition=5th|page=154|isbn=978-0-387-95203-1|access-date=October 27, 2015|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703220003/https://books.google.com/books?id=tuKGMxGRKa8C|url-status=live}}</ref> The superficial cells [[desquamation|shed]] continuously and basal cells replace them.<ref name="Dutta"/><ref name="Beckmann"/><ref name="Robboy">{{cite book|url=https://books.google.com/books?id=ab545XL-MBEC&pg=PA111|title=Robboy's Pathology of the Female Reproductive Tract|vauthors=Robboy SJ|publisher=[[Elsevier Health Sciences]]|year=2009|isbn=978-0-443-07477-6|page=111|access-date=December 15, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043208/https://books.google.com/books?id=ab545XL-MBEC&pg=PA111|url-status=live}}</ref> [[Estrogen]] induces the intermediate and superficial cells to fill with [[glycogen]].<ref name="Robboy" /><ref>{{Cite journal |vauthors=Nunn KL, Forney LJ |date=September 2016 |title=Unraveling the Dynamics of the Human Vaginal Microbiome |journal=The Yale Journal of Biology and Medicine|volume=89|issue=3|pages=331–337|issn=0044-0086|pmc=5045142|pmid=27698617}}</ref> 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 [[organelle]]s.<ref name="Blaustein2002"/><ref>{{cite book|title=Reproductive and developmental toxicology|vauthors=Gupta R |publisher=Academic Press|year=2011|isbn=978-0-12-382032-7|location=London|pages=1005}}</ref> The cells retain a usually high level of glycogen compared to other epithelial tissue in the body.<ref name="Blaustein2002" />
Under the influence of maternal estrogen, the vagina of a newborn is lined by thick stratified squamous epithelium (or mucosa) for two to four weeks after birth. Between then to [[puberty]], the epithelium remains thin with only a few layers of cuboidal cells without glycogen.<ref name="Robboy"/><ref name="G and H">{{cite book|vauthors=Hall J |title=Guyton and Hall textbook of medical physiology|date=2011|publisher=Saunders/Elsevier|location=Philadelphia |isbn=978-1-4160-4574-8|page=993|edition=12th}}</ref>  The epithelium also has few rugae and is red in color before puberty.<ref name="Dalton" /> When puberty begins, the mucosa thickens and again becomes stratified squamous epithelium with glycogen containing cells, under the influence of the girl's rising estrogen levels.<ref name="Robboy"/> Finally, the epithelium thins out from [[menopause]] onward and eventually ceases to contain glycogen, because of the lack of estrogen.<ref name="Dutta"/><ref name="Beckmann">{{cite book|vauthors=Beckmann CR|title=Obstetrics and Gynecology|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-8807-6|pages=241–245|year=2010|url=https://books.google.com/books?id=0flWgd3OJLEC&pg=PA241|access-date=October 27, 2015|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211259/https://books.google.com/books?id=0flWgd3OJLEC&pg=PA241|url-status=live}}</ref><ref name="Gad">{{cite book|vauthors=Gad SC|title=Pharmaceutical Manufacturing Handbook: Production and Processes|publisher=[[John Wiley & Sons]]|isbn=978-0-470-25980-1|page=817|year=2008|url=https://books.google.com/books?id=4c0Hp3AOi8UC&pg=PA817|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506171159/https://books.google.com/books?id=4c0Hp3AOi8UC&pg=PA817|url-status=live}}</ref>
Flattened squamous cells are more resistant to both abrasion and infection.<ref name="G and H"/> The permeability of the epithelium allows for an effective response from the [[immune system]] since [[antibodies]] and other immune components can easily reach the surface.<ref name="Anderson">{{Cite journal |vauthors=Anderson DJ, Marathe J, Pudney J |date=June 2014 |title=The Structure of the Human Vaginal Stratum Corneum and its Role in Immune Defense |journal=American Journal of Reproductive Immunology|language=en|volume=71|issue=6|pages=618–623|doi=10.1111/aji.12230|pmid=24661416 |issn=1600-0897|pmc=4024347}}</ref> The vaginal epithelium differs from the similar tissue of the skin. The [[epidermis]] of the skin is relatively resistant to water because it contains high levels of lipids. The vaginal epithelium contains lower levels of lipids. This allows the passage of water and water-soluble substances through the tissue.<ref name="Anderson" />
Keratinization happens when the epithelium is exposed to the dry external atmosphere.<ref name="Dutta"/> In abnormal circumstances, such as in [[Female genital prolapse|pelvic organ prolapse]], the mucosa may be exposed to air, becoming dry and keratinized.<ref name="Dutta2">{{cite book|vauthors=Dutta DC|title=DC Dutta's Textbook of Gynecology|year=2014|publisher=JP Medical Ltd|isbn=978-93-5152-068-9|page=206|url=https://books.google.com/books?id=40yVAwAAQBAJ&pg=PA206|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506172128/https://books.google.com/books?id=40yVAwAAQBAJ&pg=PA206|url-status=live}}</ref>
===Blood and nerve supply===
Blood is supplied to the vagina mainly via the [[vaginal artery]], which emerges from a branch of the [[internal iliac artery]] or the [[uterine artery]].<ref name="Snell" /><ref name="Zimmern">{{cite book|vauthors=Zimmern PE, Haab F, Chapple CR|title=Vaginal Surgery for Incontinence and Prolapse|publisher=[[Springer Science & Business Media]]|isbn=978-1-84628-346-8|year=2007|page=6|url=https://books.google.com/books?id=y5cYRhGJsOsC&pg=PA6|access-date=December 3, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043157/https://books.google.com/books?id=y5cYRhGJsOsC&pg=PA6|url-status=live}}</ref> The vaginal arteries [[anastamosis|anastamose]] (are joined) along the side of the vagina with the cervical branch of the uterine artery; this forms the [[Vaginal branches of uterine artery|azygos artery]],<ref name="Zimmern"/> which lies on the midline of the anterior and posterior vagina.<ref name=GRAYS2008 /> Other arteries which supply the vagina include the [[middle rectal artery]] and the [[internal pudendal artery]],<ref name="Dutta"/> all branches of the internal iliac artery.<ref name=GRAYS2008 /> Three groups of lymphatic vessels accompany these arteries; the upper group accompanies the vaginal branches of the uterine artery; a middle group accompanies the vaginal arteries; and the lower group, draining lymph from the area outside the hymen, drain to the [[inguinal lymph node]]s.<ref name=GRAYS2008/><ref>{{Cite book |vauthors=O'Rahilly R |veditors=O'Rahilly R, Müller F, Carpenter S, Swenson R |chapter-url=https://www.dartmouth.edu/~humananatomy/part_6/chapter_32.html |chapter=Blood vessels, nerves and lymphatic drainage of the pelvis |title=Basic Human Anatomy: A Regional Study of Human Structure |publisher=Dartmouth Medical School |language=en |year=2008 |access-date=December 13, 2017 |archive-date=December 2, 2017 |archive-url=https://web.archive.org/web/20171202013014/http://www.dartmouth.edu/~humananatomy/part_6/chapter_32.html |url-status=dead }}</ref> Ninety-five percent of the lymphatic channels of the vagina are within 3&nbsp;mm of the surface of the vagina.<ref name="Sabater">{{Cite journal |vauthors=Sabater S, Andres I, Lopez-Honrubia V, Berenguer R, Sevillano M, Jimenez-Jimenez E, Rovirosa A, Arenas M |date=August 9, 2017|title=Vaginal cuff brachytherapy in endometrial cancer – a technically easy treatment? |journal=Cancer Management and Research|volume=9|pages=351–362|doi=10.2147/CMAR.S119125|issn=1179-1322|pmc=5557121|pmid=28848362 |doi-access=free }}</ref>
Two main veins drain blood from the vagina, one on the left and one on the right. These form a network of smaller veins, the [[vaginal venous plexus]], on the sides of the vagina, connecting with similar venous plexuses of the [[uterine venous plexus|uterus]], [[vesical venous plexus|bladder]], and [[rectal venous plexus|rectum]]. These ultimately drain into the [[internal iliac vein]]s.<ref name=GRAYS2008 />
The nerve supply of the upper vagina is provided by the [[Sympathetic nervous system|sympathetic]] and [[Parasympathetic nervous system|parasympathetic]] areas of the [[Inferior hypogastric plexus|pelvic plexus]]. The lower vagina is supplied by the [[pudendal nerve]].<ref name="Dutta"/><ref name=GRAYS2008/>
==Function==
===Secretions===
{{Main|Vaginal discharge|Vaginal lubrication}}
Vaginal secretions are primarily from the [[uterus]], cervix, and vaginal epithelium in addition to minuscule [[vaginal lubrication]] from the [[Bartholin's gland]]s upon sexual arousal.<ref name="Dutta"/> 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]].<ref name="Dutta"/> Menstruation (also known as a "period" or "monthly") is the regular discharge of blood and mucosal tissue (known as menses) from the [[endometrium|inner lining of the uterus]] through the vagina.<ref name=Women2014Men>{{cite web|title=Menstruation and the menstrual cycle fact sheet|url=http://www.womenshealth.gov/publications/our-publications/fact-sheet/menstruation.html|website=Office of Women's Health|access-date=June 25, 2015|date=December 23, 2014|url-status=dead|archive-url=https://web.archive.org/web/20150626134338/http://www.womenshealth.gov/publications/our-publications/fact-sheet/menstruation.html|archive-date=June 26, 2015}}</ref> The vaginal mucous membrane varies in thickness and composition during the [[menstrual cycle]],<ref>{{Cite book |vauthors=Wangikar P, Ahmed T, Vangala S |chapter=Toxicologic pathology of the reproductive system |title=Reproductive and developmental toxicology |veditors=Gupta RC |date=2011 |publisher=Academic Press |isbn=978-0-12-382032-7 |location=London |page=1005 |oclc=717387050}}</ref> which is the regular, natural change that occurs in the [[female reproductive system]] (specifically the uterus and [[ovary|ovaries]]) that makes pregnancy possible.<ref name=Silverthorn>{{cite book|vauthors=Silverthorn DU|title = Human Physiology: An Integrated Approach |edition=6th |publisher = Pearson Education |location = Glenview, IL |year = 2013 | isbn = 978-0-321-75007-5 |pages=850–890}}</ref><ref name=Sherwood>{{cite book|vauthors=Sherwood L |title = Human Physiology: From Cells to Systems | edition=8th |publisher = Cengage |location = Belmont, California | year = 2013 |isbn = 978-1-111-57743-8 |pages=735–794}}</ref> Different [[feminine hygiene|hygiene products]] such as [[tampon]]s, [[menstrual cup]]s, and [[sanitary napkin]]s are available to absorb or capture menstrual blood.<ref name="Vostral">{{cite book|vauthors=Vostral SL|title=Under Wraps: A History of Menstrual Hygiene Technology|publisher=[[Lexington Books]]|isbn=978-0-7391-1385-1|year=2008|pages=1–181|url=https://books.google.com/books?id=PWA0yisYPnEC|access-date=March 22, 2018|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000252/https://books.google.com/books?id=PWA0yisYPnEC|url-status=live}}</ref>
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]].<ref name="Sloane">{{cite book|vauthors=Sloane E|title=Biology of Women|url=https://books.google.com/books?id=kqcYyk7zlHYC&pg=PA32|year=2002|publisher=[[Cengage Learning]]|isbn=978-0-7668-1142-3|pages=32, 41–42|access-date=October 27, 2015|archive-date=June 28, 2014|archive-url=https://web.archive.org/web/20140628044307/http://books.google.com/books?id=kqcYyk7zlHYC&pg=PA32|url-status=live}}</ref> 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 [[capillary|capillaries]] through the vaginal epithelium.<ref name="Sloane"/><ref name="Bourcier">{{cite book|vauthors=Bourcier A, McGuire EJ, Abrams P|title=Pelvic Floor Disorders|url=https://books.google.com/books?id=4sO5a7R1NNwC&pg=PA20|year=2004|publisher=[[Elsevier Health Sciences]]|isbn=978-0-7216-9194-7|page=20|access-date=June 8, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044806/https://books.google.com/books?id=4sO5a7R1NNwC&pg=PA20|url-status=live}}</ref><ref name="Wiederman">{{cite book|vauthors=Wiederman MW, Whitley BE Jr|title=Handbook for Conducting Research on Human Sexuality|url=https://books.google.com/books?id=L6c11oy8PGMC&q=transudation|date=2012|publisher=[[Psychology Press]]|isbn=978-1-135-66340-7|access-date=June 8, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044837/https://books.google.com/books?id=L6c11oy8PGMC&q=transudation|url-status=live}}</ref>
Before and during [[ovulation]], the mucous glands within the cervix secrete different variations of mucus, which provides an [[Alkalinity|alkaline]], [[fertile]] environment in the vaginal canal that is favorable to the survival of [[sperm]].<ref name="Cummings">{{cite book |vauthors=Cummings M |title=Human Heredity: Principles and Issues |edition=Updated |publisher=[[Cengage Learning]] |isbn=978-0-495-11308-9 |year=2006 |pages=153–154 |url=https://books.google.com/books?id=Gq06QUuNTugC&pg=PT185 |access-date=October 27, 2015 |archive-date=May 6, 2016 |archive-url=https://web.archive.org/web/20160506171032/https://books.google.com/books?id=Gq06QUuNTugC&pg=PT185 |url-status=live }}</ref> Following menopause, vaginal lubrication naturally decreases.<ref name="Sirven">{{cite book|vauthors=Sirven JI, Malamut BL|title=Clinical Neurology of the Older Adult|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-6947-1|year=2008|pages=230–232|url=https://books.google.com/books?id=c1tL8C9ryMQC&pg=PA230|access-date=June 8, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211321/https://books.google.com/books?id=c1tL8C9ryMQC&pg=PA230|url-status=live}}</ref>
=== Sexual stimulation ===
{{further|Human sexual activity|Human female sexuality}}
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.<ref name="Tara Lee">{{cite book|vauthors=Lee MT|title=Love, Sex and Everything in Between|publisher=[[Marshall Cavendish|Marshall Cavendish International Asia Pte Ltd]]|year=2013|page=76|isbn=978-981-4516-78-5|url=https://books.google.com/books?id=fnRMAgAAQBAJ&pg=PT76|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506155534/https://books.google.com/books?id=fnRMAgAAQBAJ&pg=PT76|url-status=live}}</ref> Because the vagina is not rich in nerve endings, women often do not receive sufficient sexual stimulation, or [[orgasm]], solely from vaginal penetration.<ref name="Tara Lee"/><ref name="Sex and Society">{{cite book|title=Sex and Society|volume=2|isbn=978-0-7614-7907-9|publisher=[[Marshall Cavendish Corporation]]|year=2009|page=590|url=https://books.google.com/books?id=YtsxeWE7VD0C&pg=PA590|access-date=August 20, 2020|archive-date=April 12, 2021|archive-url=https://web.archive.org/web/20210412102723/https://books.google.com/books?id=YtsxeWE7VD0C&pg=PA590|url-status=live}}</ref><ref name="Weiten">{{cite book|vauthors=Weiten W, Dunn D, Hammer E|title=Psychology Applied to Modern Life: Adjustment in the 21st Century|url=https://books.google.com/books?id=CGu96TeAZo0C&pg=PT423|date=2011|publisher=[[Cengage Learning]]|isbn=978-1-111-18663-0|page=386|access-date=October 27, 2015|archive-date=June 14, 2013|archive-url=https://web.archive.org/web/20130614031527/http://books.google.com/books?id=CGu96TeAZo0C&pg=PT423|url-status=live}}</ref> 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),<ref name="Sex and Society"/><ref name="Weiten"/><ref name="Greenberg2">{{cite book|vauthors=Greenberg JS, Bruess CE, Conklin SC|title=Exploring the Dimensions of Human Sexuality|publisher=[[Jones & Bartlett Publishers]]|year=2010|page=126|isbn=978-981-4516-78-5|url=https://books.google.com/books?id=5Sy8PJZGyWUC&pg=PA126|access-date=October 27, 2015|archive-date=May 2, 2016|archive-url=https://web.archive.org/web/20160502022058/https://books.google.com/books?id=5Sy8PJZGyWUC&pg=PA126|url-status=live}}</ref> some scientific examinations of vaginal wall innervation indicate no single area with a greater density of nerve endings.<ref name="Greenberg">{{cite book|vauthors=Greenberg JS, Bruess CE, Oswalt SB|title=Exploring the Dimensions of Human Sexuality|pages=102–104|isbn=978-1-4496-4851-0|date=2014|publisher=[[Jones & Bartlett Publishers]]|url=https://books.google.com/books?id=hm3aTuANFroC&pg=PA102|access-date=October 27, 2015|archive-date=September 10, 2015|archive-url=https://web.archive.org/web/20150910150644/https://books.google.com/books?id=hm3aTuANFroC&pg=PA102|url-status=live}}</ref><ref name="Hines">{{cite journal |vauthors=Hines T |s2cid=32381437 |date=August 2001 |title=The G-Spot: A modern gynecologic myth |journal=Am J Obstet Gynecol |volume=185 |issue=2 |pages=359–62 |doi=10.1067/mob.2001.115995 |pmid=11518892 }}{{Dead link|date=August 2020 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> Other research indicates that only some women have a greater density of nerve endings in the anterior vaginal wall.<ref name="Greenberg"/><ref name="Bullough">{{cite book|vauthors=Bullough VL, Bullough B|title=Human Sexuality: An Encyclopedia|publisher=[[Routledge]]|year=2014|pages=229–231|isbn=978-1-135-82509-6|url=https://books.google.com/books?id=UHymAgAAQBAJ&pg=PA229|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506163017/https://books.google.com/books?id=UHymAgAAQBAJ&pg=PA229|url-status=live}}</ref> Because of the fewer nerve endings in the vagina, childbirth pain is significantly more tolerable.<ref name="Weiten"/><ref name="Balon, Segraves">{{cite book |vauthors=Balon R, Segraves RT |title=Clinical Manual of Sexual Disorders |publisher=[[American Psychiatric Association|American Psychiatric Pub]] |year=2009 |page=258 |isbn=978-1-58562-905-3 |url=https://books.google.com/books?id=YuP3Hb0TMLQC&pg=PA258 |access-date=October 27, 2015 |archive-date=June 27, 2014 |archive-url=https://web.archive.org/web/20140627021747/http://books.google.com/books?id=YuP3Hb0TMLQC&pg=PA258 |url-status=live }}</ref><ref name="Rosenthal">{{cite book|vauthors=Rosenthal M|title=Human Sexuality: From Cells to Society|url=https://books.google.com/books?id=d58z5hgQ2gsC&pg=PT96|date=2012|publisher=[[Cengage Learning]]|isbn=978-0-618-75571-4|page=76|access-date=October 27, 2015|archive-date=December 10, 2020|archive-url=https://web.archive.org/web/20201210125644/https://books.google.com/books?id=d58z5hgQ2gsC&pg=PT96|url-status=live}}</ref>
Most women require direct stimulation of the [[clitoris]] to orgasm.<ref name="Sex and Society"/><ref name="Weiten"/> 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.<ref name="Sex and Society"/><ref name="O'Connell">{{cite journal |vauthors=O'Connell HE, Sanjeevan KV, Hutson JM |s2cid=26109805 |title=Anatomy of the clitoris |journal=The Journal of Urology |volume=174 |issue=4 Pt 1 |pages=1189–95 |date=October 2005 |pmid=16145367 |doi=10.1097/01.ju.0000173639.38898.cd}}
*{{cite news |author=Sharon Mascall |date=June 11, 2006 |title=Time for rethink on the clitoris |work=[[BBC News]] |url=http://news.bbc.co.uk/2/hi/health/5013866.stm}}</ref><ref name="Kilchevsky">{{cite journal |title=Is the Female G-Spot Truly a Distinct Anatomic Entity? |journal=[[The Journal of Sexual Medicine]] |volume=9 |date=January 2012 |pmid=22240236 |doi=10.1111/j.1743-6109.2011.02623.x|vauthors=Kilchevsky A, Vardi Y, Lowenstein L, Gruenwald I |issue=3 |pages=719–26}}
*{{cite news |date=January 19, 2012 |title=G-Spot Does Not Exist, 'Without A Doubt,' Say Researchers |work=[[The Huffington Post]] |url=http://www.huffingtonpost.com/2012/01/19/g-spot-does-not-exist_n_1215822.html}}</ref>
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.<ref name="Heffner">{{cite book|vauthors=Heffner LJ, Schust DJ|title=The Reproductive System at a Glance|page=39|isbn=978-1-118-60701-5|date=2014|publisher=[[John Wiley & Sons]]|url=https://books.google.com/books?id=JuvcAgAAQBAJ&pg=PA39|access-date=October 27, 2015|archive-date=April 28, 2016|archive-url=https://web.archive.org/web/20160428170307/https://books.google.com/books?id=JuvcAgAAQBAJ&pg=PA39|url-status=live}}</ref> 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.<ref name="Heffner"/><ref name="Silbernagl">{{cite book|vauthors=Silbernagl S, Despopoulos A|title=Color Atlas of Physiology|publisher=[[Thieme Medical Publishers|Thieme]]|page=310|isbn=978-1-4496-4851-0|date=2011|url=https://books.google.com/books?id=WyuCGhv4kvwC&pg=PA310|access-date=October 27, 2015|archive-date=May 7, 2016|archive-url=https://web.archive.org/web/20160507064443/https://books.google.com/books?id=WyuCGhv4kvwC&pg=PA310|url-status=live}}</ref> 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.<ref name="Heffner"/> This is known as the tenting or ballooning effect.<ref name="Carroll 2">{{cite book|vauthors=Carroll JL|title=Sexuality Now: Embracing Diversity|publisher=[[Cengage Learning]]|page=271|isbn=978-1-305-44603-8|date=2015|url=https://books.google.com/books?id=cy9-BAAAQBAJ&pg=PT271|access-date=August 21, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044828/https://books.google.com/books?id=cy9-BAAAQBAJ&pg=PT271|url-status=live}}</ref>  As the elastic walls of the vagina [[Vaginal contraction|stretch or contract]], with support from the pelvic muscles, to wrap around the inserted penis (or other object),<ref name="Greenberg2"/> this creates friction for the penis and helps to cause a man to experience orgasm and [[ejaculation]], which in turn enables [[Human fertilization|fertilization]].<ref name="Publishing">{{cite book|vauthors=Brewster S, Bhattacharya S, Davies J, Meredith S, Preston P|title=The Pregnant Body Book|publisher=[[Penguin Books|Penguin]]|pages=66–67|isbn=978-0-7566-8712-0|date=2011|url=https://books.google.com/books?id=yBIuIN40JaQC&pg=PA66|access-date=March 4, 2015|archive-date=May 15, 2015|archive-url=https://web.archive.org/web/20150515122827/https://books.google.com/books?id=yBIuIN40JaQC&pg=PA66|url-status=live}}</ref>
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.<ref name="Greenberg"/><ref name="Bullough"/> 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 gland]]s, a female [[Homology (biology)|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.<ref name="Greenberg"/><ref name="Hines"/><ref name="Bullough"/> 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.<ref name="Greenberg"/><ref name="Balon, Segraves"/><ref name="Kilchevsky"/>
===Childbirth===
{{Main|Childbirth}}
The vagina is the birth canal for the [[vaginal delivery|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.<ref name=Linnard-Palmer2017>{{Cite book|last1=Linnard-Palmer|first1=Luanne|last2=Coats|first2=Gloria|title=Safe Maternity and Pediatric Nursing Care|publisher=[[F. A. Davis Company]]|year=2017|isbn=978-0-8036-2494-8|page=108|language=en}}</ref> 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.<ref name="Callahan">{{cite book|vauthors=Callahan T, Caughey AB|title=Blueprints Obstetrics and Gynecology|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-1-4511-1702-8|year=2013|page=40|url=https://books.google.com/books?id=eKC1B3BhlxUC&pg=PA40|access-date=January 8, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703215955/https://books.google.com/books?id=eKC1B3BhlxUC&pg=PA40|url-status=live}}</ref> Among women giving birth for the first time, [[Braxton Hicks contractions]] are mistaken for actual [[Uterine contraction#Childbirth|contractions]],<ref name="Pillitteri">{{cite book|vauthors=Pillitteri A|title=Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-1-4698-3322-4|year=2013|page=298|url=https://books.google.com/books?id=26idAgAAQBAJ&pg=PA298|access-date=January 3, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211312/https://books.google.com/books?id=26idAgAAQBAJ&pg=PA298|url-status=live}}</ref> but they are instead a way for the body to prepare for true labor. They do not signal the beginning of labor,<ref name=Raines2021>{{Cite book|last1=Raines|first1=Deborah|last2=Cooper|first2=Danielle B.|url=https://www.ncbi.nlm.nih.gov/books/NBK470546/|title=Braxton Hicks Contractions|publisher=StatPearls Publishing|year=2021|pmid=29262073|language=en}}</ref> but they are usually very strong in the days leading up to labor.<ref name="Pillitteri"/><ref name=Raines2021/>
As the body prepares for childbirth, the cervix softens, [[Cervical effacement|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.<ref name=Forbes2020>{{Cite book|last1=Forbes|first1=Helen|last2=Watt|first2=Elizabethl|url=https://www.elsevier.com/books/jarviss-health-assessment-and-physical-examination/forbes/978-0-7295-4337-8|title=Jarvis's Health Assessment and Physical Examination|publisher=[[Elsevier Health Sciences]]|year=2020|isbn=978-0-729-58793-8|edition=3|page=834|language=en}}</ref> As the fetus settles into the pelvis, pain from the [[sciatic nerve]]s, increased vaginal discharge, and increased urinary frequency can occur.<ref name=Forbes2020/> 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.<ref name="Orshan">{{cite book|vauthors=Orshan SA |title=Maternity, Newborn, and Women's Health Nursing: Comprehensive Care Across the Lifespan|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-4254-2|year=2008|pages=[https://archive.org/details/maternitynewborn0000orsh/page/585 585]–586 |url=https://archive.org/details/maternitynewborn0000orsh|url-access=registration }}</ref>
The fetus begins to lose the support of the cervix when contractions begin. With [[cervical dilation]] reaching 10&nbsp;cm to accommodate the head of the fetus, the head moves from the uterus to the vagina.<ref name=Linnard-Palmer2017/><ref name=Hutchison2022>{{Cite book|last1=Hutchison|first1=Julia|last2=Mahdy|first2=Heba|last3=Hutchison|first3=Justin|url=https://www.ncbi.nlm.nih.gov/books/NBK544290/|title=Stages of Labor |publisher=StatPearls Publishing|year=2022|pmid=31335010|language=en}}</ref> The elasticity of the vagina allows it to stretch to many times its normal diameter in order to deliver the child.<ref>{{Cite journal|last1=Clark–Patterson|first1=Gabrielle|last2=Domingo|first2=Mari|last3=Miller|first3=Kristin|date= June 2022|title=Biomechanics of pregnancy and vaginal delivery|journal=Current Opinion in Biomedical Engineering|volume=22|page=100386 |doi=10.1016/j.cobme.2022.100386|s2cid=247811789 |issn=2468-4511|doi-access=free}}</ref>
Vaginal births are more common, but if there is a risk of complications a [[caesarean section]] (C-section) may be performed.<ref name=NIH>{{cite web|title=Pregnancy Labor and Birth|url=https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth|publisher=Office on Women's Health, U.S. Department of Health and Human Services|access-date=July 15, 2017|date=February 1, 2017|url-status=live|archive-url=https://web.archive.org/web/20170728021055/https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth|archive-date=July 28, 2017}}</ref> 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.<ref name="Ricci">{{cite book |vauthors=Ricci SS, Kyle T |title=Maternity and Pediatric Nursing|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-8055-1|year=2009|pages=[https://archive.org/details/maternitypediatr0000ricc/page/431 431]–432 |url=https://archive.org/details/maternitypediatr0000ricc|url-access=registration }}</ref>
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.<ref name="Fletcher">{{cite journal|vauthors=Fletcher, S, Grotegut, CA, James, AH |title=Lochia patterns among normal women: a systematic review.|journal=Journal of Women's Health |date=December 2012 |volume=21 |issue=12 |pages=1290–4 |doi=10.1089/jwh.2012.3668 |pmid=23101487}}</ref>
=== Vaginal microbiota ===
{{Main|Vaginal flora}}
{{further|List of microbiota species of the lower reproductive tract of women}}[[File:Lactobacilli (Gram stain).jpg|thumb|Gram stain of lactobacilli and squamous epithelial cells in vaginal swab]]
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.<ref name="Anderson" /> 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.<ref name="PetrovaLievens2015">{{cite journal |vauthors=Petrova MI, Lievens E, Malik S, Imholz N, Lebeer S |title=Lactobacillus species as biomarkers and agents that can promote various aspects of vaginal health|journal=Frontiers in Physiology|volume=6|pages=81|year=2015|issn=1664-042X|doi=10.3389/fphys.2015.00081|pmid=25859220|pmc=4373506|doi-access=free}}</ref> These species [[Metabolism|metabolize]] glycogen, breaking it down into sugar. ''Lactobacilli'' metabolize the sugar into glucose and lactic acid.<ref name = "King"/> Under the influence of hormones, such as estrogen, progesterone and [[follicle-stimulating hormone]] (FSH), the vaginal ecosystem undergoes cyclic or periodic changes.<ref name="King">{{cite book|vauthors=King TL, Brucker MC|title=Pharmacology for Women's Health|publisher=[[Jones & Bartlett Publishers]]|isbn=978-1-4496-1073-9|year=2010|pages=951–953|url=https://books.google.com/books?id=o_rHHCsIpckC&pg=PA951|access-date=October 27, 2015|archive-date=May 2, 2016|archive-url=https://web.archive.org/web/20160502023957/https://books.google.com/books?id=o_rHHCsIpckC&pg=PA951|url-status=live}}</ref>
==Clinical significance==
===Pelvic examinations===
[[File:Spéculum en plastique.jpg|thumb|right|alt=Photograph of a transparent speculum on a white surface|A disposable plastic bi-valved vaginal [[Speculum (medical)|speculum]] used in [[Pelvic examination|gynecological examination]]]]
[[File:Cervix uteri, breastfeeding woman after 2 births.jpg|thumb|alt=Photograph of a cervix as described in caption|A normal [[cervix]] of an adult as seen through the vagina ({{lang|la|per vaginam}} or PV) using a [[Speculum (medical)#Vaginal|bivalved vaginal speculum]]. The blades of the speculum are above and below and stretched vaginal walls are seen on the left and right.]]
Vaginal health can be assessed during a [[pelvic examination]], along with the health of most of the organs of the female reproductive system.<ref name="Damico"/><ref>{{Cite web|url=https://www.cancer.gov/publications/dictionaries/cancer-terms|title=NCI Dictionary of Cancer Terms|website=National Cancer Institute|access-date=January 5, 2018|date=February 2, 2011|archive-date=September 14, 2018|archive-url=https://web.archive.org/web/20180914111122/https://www.cancer.gov/publications/dictionaries/cancer-terms|url-status=live}}</ref><ref name="Vickery">{{cite book|vauthors=Vickery DM, Fries JF|title=Take Care of Yourself: The Complete Illustrated Guide to Medical Self-Care|publisher=[[Da Capo Press]]|isbn=978-0-7867-5218-8|year=2013|url=https://books.google.com/books?id=dXqEAAAAQBAJ|access-date=October 27, 2015|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000858/https://books.google.com/books?id=dXqEAAAAQBAJ|url-status=live}}</ref> 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.<ref>{{Cite web|url=https://www.cdc.gov/cancer/knowledge/provider-education/cervical/recommendations.htm|title=CDC - Cervical Cancer Screening Recommendations and Considerations - Gynecologic Cancer Curriculum - Inside Knowledge Campaign|website=Centers for Disease Control and Prevention|language=en-us|access-date=January 19, 2018|archive-date=January 19, 2018|archive-url=https://web.archive.org/web/20180119060654/https://www.cdc.gov/cancer/knowledge/provider-education/cervical/recommendations.htm|url-status=live}}</ref>  However, other countries do not recommend pap testing in non-sexually active women.<ref name=US2012>{{Cite journal|vauthors=Moyer VA|s2cid=36965456 |date=September 2016 |title=Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.|journal=Annals of Internal Medicine|volume=156|issue=12|pages=880–91|pmid=22711081|doi=10.7326/0003-4819-156-12-201206190-00424}}</ref> Guidelines on frequency vary from every three to five years.<ref name=US2012/><ref name=Saslow2012>{{Cite journal|vauthors= Saslow D |title=American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer|journal=Journal of Lower Genital Tract Disease|volume=16|issue=3|pages=175–204|year =2012|doi=10.1097/LGT.0b013e31824ca9d5|pmid=22418039|pmc=3915715}}</ref><ref name="cancer.org">{{cite web|title=Can Cervical Cancer Be Prevented?|publisher=[[American Cancer Society]]|date=November 1, 2017|access-date=January 7, 2018|url=http://www.cancer.org/Cancer/CervicalCancer/DetailedGuide/cervical-cancer-prevention|archive-date=December 10, 2016|archive-url=https://web.archive.org/web/20161210123552/http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-prevention|url-status=live}}</ref> Routine pelvic examination on women who are not pregnant and lack symptoms may be more harmful than beneficial.<ref name="Qa2014">{{cite journal|vauthors=Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD |date=July 1, 2014|title=Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians.|journal=Annals of Internal Medicine|volume=161|issue=1|pages=67–72|doi=10.7326/M14-0701|pmid=24979451|citeseerx=10.1.1.691.4471|s2cid=12370761 }}[Free text]</ref> A normal finding during the pelvic exam of a pregnant woman is a bluish tinge to the vaginal wall.<ref name="Damico"/>
Pelvic exams are most often performed when there are unexplained symptoms of discharge, pain, unexpected bleeding or urinary problems.<ref name="Damico">{{cite book|title=Health & physical assessment in nursing|vauthors=Damico D|publisher=Pearson|year=2016|isbn=978-0-13-387640-6|location=Boston|page=665}}</ref><ref name="Mayo">{{Cite web|url=https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135|title=Pelvic exam - About - Mayo Clinic|website=www.mayoclinic.org|language=en|access-date=January 4, 2018|archive-date=January 5, 2018|archive-url=https://web.archive.org/web/20180105012302/https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135|url-status=live}}</ref><ref name=AW2007>{{cite book|vauthors=Hinrichsen C, Lisowski P|title=Anatomy Workbook|publisher=[[World Scientific Publishing Company]]|isbn=978-981-256-906-6|year=2007|page=101|url=https://books.google.com/books?id=1rxhPgAACAAJ&q=Anatomy+Workbook+Colin+Hinrichsen|access-date=October 19, 2020|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000703/https://books.google.com/books?id=1rxhPgAACAAJ&q=Anatomy+Workbook+Colin+Hinrichsen|url-status=live}}</ref> 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 [[Nodule (medicine)|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.<ref name="Damico"/> Examination of the vagina may also be done during a [[cavity search]].<ref name="Stering">{{cite book|url=https://books.google.com/books?id=2rlUcxpsck4C&pg=PA80|title=Police Officer's Handbook: An Introductory Guide|vauthors=Stering R|publisher=[[Jones & Bartlett Learning]]|year=2004|isbn=978-0-7637-4789-3|page=80|access-date=April 2, 2017|archive-date=April 3, 2017|archive-url=https://web.archive.org/web/20170403111503/https://books.google.com/books?id=2rlUcxpsck4C&pg=PA80|url-status=live}}</ref>
Lacerations or other injuries to the vagina can occur during [[sexual assault]] or other [[sexual abuse]].<ref name="Dalton" /><ref name="Damico" /> 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.<ref name="Dalton" /> If consent is given, a pelvic examination is part of the assessment of sexual assault.<ref name = Hoffman>{{Cite book |title=Williams gynecology |date=2012|publisher=McGraw-Hill Medical |vauthors=Hoffman B, Schorge J, Schaffer J, Halvorson L, Bradshaw K, Cunningham F |isbn=978-0-07-171672-7|edition=2nd |location=New York|pages=371|oclc=779244257}}</ref> Pelvic exams are also performed during pregnancy, and women with high risk pregnancies have exams more often.<ref name="Damico"/><ref>{{Cite web|url=https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests|title=Prenatal care and tests {{!}} womenshealth.gov|website=womenshealth.gov|language=en|access-date=January 5, 2018|date=December 13, 2016|archive-date=April 18, 2019|archive-url=https://web.archive.org/web/20190418234111/https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests|url-status=live}}{{PD-notice}}</ref>
===Medications===
[[Intravaginal administration]] is a [[route of administration]] where the medication is inserted into the vagina as a creme or tablet. [[Pharmacological]]ly, this has the potential advantage of promoting [[therapeutic effect]]s primarily in the vagina or nearby structures (such as the [[vaginal portion of cervix]]) with limited systemic [[adverse effect]]s compared to other routes of administration.<ref name="Ranade">{{cite book |vauthors=Ranade VV, Cannon JB |title=Drug Delivery Systems |edition=3rd |publisher=[[CRC Press]] |isbn=978-1-4398-0618-0 |year=2011 |page=337 |url=https://books.google.com/books?id=PBfLKBTQk0cC&pg=PA337 |access-date=October 27, 2015 |archive-date=May 6, 2016 |archive-url=https://web.archive.org/web/20160506164911/https://books.google.com/books?id=PBfLKBTQk0cC&pg=PA337 |url-status=live }}</ref><ref name="Lehne">{{cite book|vauthors=Lehne RA, Rosenthal L|title=Pharmacology for Nursing Care|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-29354-9|year=2014|page=1146|url=https://books.google.com/books?id=udTsAwAAQBAJ&pg=PA1146|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506162710/https://books.google.com/books?id=udTsAwAAQBAJ&pg=PA1146|url-status=live}}</ref> Medications used to ripen the cervix and induce labor are commonly administered via this route, as are estrogens, contraceptive agents, [[propranolol]], and [[antifungal medication|antifungals]]. [[Vaginal ring]]s can also be used to deliver medication, including [[birth control]] in [[contraceptive vaginal ring]]s. These are inserted into the vagina and provide continuous, low dose and consistent drug levels in the vagina and throughout the body.<ref>{{Cite journal|vauthors=Srikrishna S, Cardozo L |s2cid=25185650 |date=April 2013 |title=The vagina as a route for drug delivery: a review |journal=International Urogynecology Journal|language=en|volume=24|issue=4|pages=537–543|doi=10.1007/s00192-012-2009-3|pmid=23229421 |issn=0937-3462}}</ref><ref>{{Cite web|url=https://www.medscape.org/viewarticle/504375_5|title=The Benefits of Vaginal Drug Administration—Communicating Effectively With Patients: The Vagina: New Options for the Administration of Medications|date=January 8, 2018|website=www.medscape.org|publisher=Medscape|access-date=January 8, 2018|archive-date=October 18, 2015|archive-url=https://web.archive.org/web/20151018010055/http://www.medscape.org/viewarticle/504375_5|url-status=live}}</ref>
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#Anesthesia|pudendal nerve block]] relieves birth pain. The medicine does not harm the child, and is without significant complications.<ref name="Maclean2011">{{cite book|title=Gynaecology |vauthors=Maclean A, Reid W |publisher=Churchill Livingstone/Elsevier|year=2011|isbn=978-0-7020-3120-5|veditors=Shaw R |location=Edinburgh New York|pages=599–612|chapter=40}}</ref>
===Infections, diseases, and safe sex===
{{Main|Vaginal disease|Safe sex}}
Vaginal infections or diseases include [[Vaginal yeast infection|yeast infection]], [[vaginitis]], [[sexually transmitted infection]]s (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]].<ref>{{Cite journal|vauthors = Nardis C, Mosca L, Mastromarino P|date=September 2013|title=Vaginal microbiota and viral sexually transmitted diseases|journal=Annali di Igiene: Medicina Preventiva e di Comunita|language = en | volume=25|issue=5|pages=443–456|issn=1120-9135|pmid=24048183|doi=10.7416/ai.2013.1946}}</ref> The healthy vagina of a woman of child-bearing age is [[acid]]ic, with a [[pH#Living systems|pH]] normally ranging between 3.8 and 4.5.<ref name="King"/> The low pH prohibits growth of many strains of [[pathogen]]ic microbes.<ref name="King"/> The acidic balance of the vagina may also be affected by semen,<ref>{{Cite journal |last1=Baldewijns |first1=Silke |last2=Sillen |first2=Mart |last3=Palmans |first3=Ilse |last4=Vandecruys |first4=Paul |last5=Van Dijck |first5=Patrick |last6=Demuyser |first6=Liesbeth |date=2021-07-02 |title=The Role of Fatty Acid Metabolites in Vaginal Health and Disease: Application to Candidiasis |journal=Frontiers in Microbiology |volume=12 |doi=10.3389/fmicb.2021.705779 |doi-access=free |issn=1664-302X |pmc=8282898 |pmid=34276639}}</ref><ref>{{Cite journal |last1=Jewanraj |first1=Janine |last2=Ngcapu |first2=Sinaye |last3=Liebenberg |first3=Lenine J. P. |date=Nov 2021 |title=Semen: A modulator of female genital tract inflammation and a vector for HIV-1 transmission |journal=American Journal of Reproductive Immunology |language=en |volume=86 |issue=5 |pages=e13478 |doi=10.1111/aji.13478 |issn=1046-7408 |pmc=9286343 |pmid=34077596}}</ref> pregnancy, menstruation, [[diabetes]] or other illness, [[oral contraceptive pill|birth control pills]], certain [[antibiotics]], poor diet, and stress.<ref name="Leifer">{{cite book|vauthors=Leifer G|title=Introduction to Maternity and Pediatric Nursing - E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-29358-7|year=2014|page=276|url=https://books.google.com/books?id=T5I3BQAAQBAJ&pg=PA276|access-date=December 20, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211423/https://books.google.com/books?id=T5I3BQAAQBAJ&pg=PA276|url-status=live}}</ref> Any of these changes to the acidic balance of the vagina may contribute to yeast infection.<ref name="AAOS">{{cite book |url=https://books.google.com/books?id=6yMMs8OCqU4C&pg=PA766 |title=AEMT: Advanced Emergency Care and Transportation of the Sick and Injured |vauthors=[[AAOS]] |publisher=[[Jones & Bartlett Publishers]] |year=2011 |isbn=978-1-4496-8428-0 |page=766 |access-date=December 20, 2017 |archive-url=https://web.archive.org/web/20190703215958/https://books.google.com/books?id=6yMMs8OCqU4C&pg=PA766 |archive-date=July 3, 2019 |url-status=live}}</ref> 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.<ref name="King"/><ref name="Alldredge">{{cite book|vauthors=Alldredge BK, Corelli RL, Ernst ME|title=Koda-Kimble and Young's Applied Therapeutics: The Clinical Use of Drugs|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-1-60913-713-7|year=2012|pages=1636–1641|url=https://books.google.com/books?id=qcVpuHngXK0C&pg=PA1636|access-date=October 27, 2015|archive-date=April 24, 2016|archive-url=https://web.archive.org/web/20160424182703/https://books.google.com/books?id=qcVpuHngXK0C&pg=PA1636|url-status=live}}</ref> Vaginal flora populated by a number of different bacteria characteristic of bacterial vaginosis increases the risk of adverse pregnancy outcomes.<ref>{{Cite journal|vauthors=Lamont RF, Sobel JD, Akins RA, Hassan SS, Chaiworapongsa T, Kusanovic JP, Romero R |date=April 2011 |title=The vaginal microbiome: new information about genital tract flora using molecular based techniques |journal=BJOG: An International Journal of Obstetrics & Gynaecology|language=en|volume=118|issue=5|pages=533–549|doi=10.1111/j.1471-0528.2010.02840.x |pmc=3055920 |pmid=21251190 |issn=1471-0528}}</ref> During a pelvic exam, samples of vaginal fluids may be taken to screen for sexually transmitted infections or other infections.<ref name="Damico"/><ref>{{Cite web|url=https://www.cancer.gov/publications/dictionaries/cancer-terms|title=NCI Dictionary of Cancer Terms|website=National Cancer Institute|access-date=January 4, 2018|date=February 2, 2011|archive-date=September 14, 2018|archive-url=https://web.archive.org/web/20180914111122/https://www.cancer.gov/publications/dictionaries/cancer-terms|url-status=live}}{{PD-notice}}</ref>
Because the vagina is self-cleansing, it usually does not need special hygiene.<ref name="Grimes">{{cite book|vauthors=Grimes JA, Smith LA, Fagerberg K|title=Sexually Transmitted Disease: An Encyclopedia of Diseases, Prevention, Treatment, and Issues: An Encyclopedia of Diseases, Prevention, Treatment, and Issues|publisher=[[ABC-CLIO]]|isbn=978-1-4408-0135-8|year=2013|pages=144, 590–592|url=https://books.google.com/books?id=wagNAgAAQBAJ&pg=PA144|access-date=December 11, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043222/https://books.google.com/books?id=wagNAgAAQBAJ&pg=PA144|url-status=live}}</ref> Clinicians generally discourage the practice of [[douche|douching]] for maintaining vulvovaginal health.<ref name="Grimes"/><ref>{{cite journal |author2-link=Sten H. Vermund| vauthors = Martino JL, Vermund SH | title = Vaginal douching: evidence for risks or benefits to women's health | journal = Epidemiologic Reviews | volume = 24 | issue = 2 | pages = 109–24 | date = 2002 | pmid = 12762087 | pmc = 2567125 | doi = 10.1093/epirev/mxf004 }}</ref> Since the vaginal flora gives protection against disease, a disturbance of this balance may lead to infection and abnormal discharge.<ref name="Grimes"/> Vaginal discharge may indicate a vaginal infection by color and odor, or the resulting symptoms of discharge, such as irritation or burning.<ref name="McGrath">{{cite book|vauthors=McGrath J, Foley A|title=Emergency Nursing Certification (CEN): Self-Assessment and Exam Review|publisher=[[McGraw Hill Professional]]|isbn=978-1-259-58715-3|year=2016|page=138}}</ref><ref name="Wright">{{cite book|vauthors=Wright, WF|title=Essentials of Clinical Infectious Diseases|publisher=[[Demos Medical Publishing]]|isbn=978-1-61705-153-1|year=2013|page=269|url=https://books.google.com/books?id=gGlXEntvU34C&pg=PA269|access-date=January 3, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211233/https://books.google.com/books?id=gGlXEntvU34C&pg=PA269|url-status=live}}</ref> 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.<ref name="McGrath"/> While vaginitis is an inflammation of the vagina, and is attributed to infection, hormonal issues, or irritants,<ref name="Ferri">{{cite book|vauthors=Ferri FF|title=Ferri's Clinical Advisor 2013|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-08373-7|year=2012|pages=1134–1140|url=https://books.google.com/books?id=OR3VERnvzzEC&pg=PA1134|access-date=October 27, 2015|archive-date=March 26, 2015|archive-url=https://web.archive.org/web/20150326122056/http://books.google.com/books?id=OR3VERnvzzEC&pg=PA1134|url-status=live}}</ref><ref name="Sommers">{{cite book|vauthors=Sommers MS, Fannin E|title=Diseases and Disorders: A Nursing Therapeutics Manual|publisher=[[F.A. Davis]]|isbn=978-0-8036-4487-8|year=2014|page=115|url=https://books.google.com/books?id=pIEsBQAAQBAJ&pg=PA1115|access-date=March 10, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044834/https://books.google.com/books?id=pIEsBQAAQBAJ&pg=PA1115|url-status=live}}</ref> [[vaginismus]] is an involuntary tightening of the vagina muscles during vaginal penetration that is caused by a [[conditioned reflex]] or disease.<ref name="Ferri"/> 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.<ref name="Wright"/>
[[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.<ref name="Hales">{{Cite book|vauthors=Hales D|title=An Invitation to Health Brief 2010-2011|publisher=[[Cengage Learning]]|year=2008|pages=269–271|isbn=978-0-495-39192-0|url=https://books.google.com/books?id=oP91HVIMPRIC&pg=PA269|access-date=October 27, 2015|archive-date=December 31, 2013|archive-url=https://web.archive.org/web/20131231143640/http://books.google.com/books?id=oP91HVIMPRIC&pg=PA269|url-status=live}}</ref><ref name="Alexander">{{cite book|vauthors=Alexander W, Bader H, LaRosa JH|title=New Dimensions in Women's Health|isbn=978-1-4496-8375-7|publisher=[[Jones & Bartlett Learning|Jones & Bartlett Publishers]]|year=2011|page=211|url=https://books.google.com/books?id=GVPHhIM3IZ0C&pg=PA211|access-date=October 27, 2015|archive-date=July 15, 2014|archive-url=https://web.archive.org/web/20140715160215/http://books.google.com/books?id=GVPHhIM3IZ0C&pg=PA211|url-status=live}}</ref> Safe sex commonly involves the use of [[condom]]s, and sometimes [[female condom]]s (which give women more control). Both types can help avert pregnancy by preventing semen from coming in contact with the vagina.<ref name="Knox and Schacht">{{cite book|vauthors=Knox D, Schacht C|title=Choices in Relationships: Introduction to Marriage and the Family|isbn=978-0-495-09185-1|publisher=[[Cengage Learning]]|year=2007|pages=296–297|url=https://books.google.com/books?id=Q3XD0VEYGSUC&pg=PA296|access-date=January 16, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211359/https://books.google.com/books?id=Q3XD0VEYGSUC&pg=PA296|url-status=live}}</ref><ref name="Kumar and Gupta">{{cite book|vauthors=Kumar B, Gupta S|title=Sexually Transmitted Infections|isbn=978-81-312-2978-1|publisher=[[Elsevier Health Sciences]]|year=2014|pages=126–127|url=https://books.google.com/books?id=kQ9tAwAAQBAJ&pg=PA126|access-date=January 16, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211232/https://books.google.com/books?id=kQ9tAwAAQBAJ&pg=PA126|url-status=live}}</ref> There is, however, little research on whether female condoms are as effective as male condoms at preventing STIs,<ref name="Kumar and Gupta"/> 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.<ref name="Hornstein and Schwerin">{{cite book|vauthors=Hornstein T, Schwerin JL|title=Biology of Women|isbn=978-1-4354-0033-7|publisher=[[Cengage Learning]]|year=2012|pages=126–127|url=https://books.google.com/books?id=2iD1CAAAQBAJ&pg=PA326|access-date=January 16, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211314/https://books.google.com/books?id=2iD1CAAAQBAJ&pg=PA326|url-status=live}}</ref>
The vaginal lymph nodes often trap [[cancer]]ous 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.<ref name="Sabater"/> 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.<ref name = NIHI>{{cite web |url=https://www.cancer.gov/types/vaginal/hp/vaginal-treatment-pdq#section/_45 |publisher=National Institutes of Health |website=National Cancer Institute |date=February 9, 2017 |title=Stage I Vaginal Cancer |access-date=December 14, 2017 |archive-date=April 9, 2019 |archive-url=https://web.archive.org/web/20190409134644/https://www.cancer.gov/types/vaginal/hp/vaginal-treatment-pdq#section/_45 |url-status=live }}{{PD-notice}}</ref>
[[Vaginal cancer]] and [[vulvar cancer]] are very rare, and primarily affect older women.<ref name="Salhan">{{cite book|vauthors=Salhan S|title=Textbook of Gynecology|publisher=JP Medical Ltd|isbn=978-93-5025-369-4|year=2011|page=270|url=https://books.google.com/books?id=4g5Wgc3Bh18C&pg=PA270|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506180140/https://books.google.com/books?id=4g5Wgc3Bh18C&pg=PA270|url-status=live}}</ref><ref name="Paludi">{{cite book|vauthors=Paludi MA|title=The Praeger Handbook on Women's Cancers: Personal and Psychosocial Insights|publisher=[[ABC-CLIO]]|isbn=978-1-4408-2814-0|year=2014|page=111|url=https://books.google.com/books?id=HQpvBAAAQBAJ&pg=PA111|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506162920/https://books.google.com/books?id=HQpvBAAAQBAJ&pg=PA111|url-status=live}}</ref> [[Cervical cancer]] (which is relatively common) increases the risk of vaginal cancer,<ref name="cancer.org2">{{cite web|title=What Are the Risk Factors for Vaginal Cancer?|publisher=[[American Cancer Society]]|date=October 19, 2017|access-date=January 5, 2018|url=https://www.cancer.org/cancer/vaginal-cancer/causes-risks-prevention/risk-factors.html|archive-date=January 6, 2018|archive-url=https://web.archive.org/web/20180106120444/https://www.cancer.org/cancer/vaginal-cancer/causes-risks-prevention/risk-factors.html|url-status=live}}</ref> 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.<ref name="cancer.org2"/><ref name="Salhan"/><ref name="Chi">{{cite book|vauthors=Chi D, Berchuck A, Dizon DS, Yashar CM|title=Principles and Practice of Gynecologic Oncology|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-1-4963-5510-2|year=2017|page=87|url=https://books.google.com/books?id=4RYIDgAAQBAJ&pg=PT87|access-date=December 14, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211236/https://books.google.com/books?id=4RYIDgAAQBAJ&pg=PT87|url-status=live}}</ref> Cervical cancer may be prevented by pap smear screening and [[HPV vaccine]]s, but HPV vaccines only cover HPV types 16 and 18, the cause of 70% of cervical cancers.<ref name="Berek">{{cite book |vauthors=Berek JS, Hacker NF |title=Berek and Hacker's Gynecologic Oncology|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-9512-8|year=2010|page=225 |url=https://books.google.com/books?id=bA3ODcFV-5oC&pg=PA225}}</ref><ref name="Bibbo">{{cite book|vauthors=Bibbo M, Wilbur D|title=Comprehensive Cytopathology E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-26576-8|year=2014|page=49|url=https://books.google.com/books?id=2FPOAwAAQBAJ&pg=PA49|access-date=December 14, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211319/https://books.google.com/books?id=2FPOAwAAQBAJ&pg=PA49|url-status=live}}</ref>  Some symptoms of cervical and vaginal cancer are [[dyspareunia]], and abnormal [[vaginal bleeding]] or vaginal discharge, especially [[postcoital bleeding|after sexual intercourse]] or menopause.<ref name="Daniels">{{cite book|vauthors=Daniels R, Nicoll LH|title=Contemporary Medical-Surgical Nursing|publisher=[[Cengage Learning]]|isbn=978-1-133-41875-7|year=2011|page=1776|url=https://books.google.com/books?id=wUAJAAAAQBAJ&pg=PA1776|access-date=December 14, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703220036/https://books.google.com/books?id=wUAJAAAAQBAJ&pg=PA1776|url-status=live}}</ref><ref name="Washington">{{cite book|vauthors=Washington CM, Leaver DT|title=Principles and Practice of Radiation Therapy|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-28781-4|year=2015|page=749|url=https://books.google.com/books?id=zzMwBwAAQBAJ&pg=PA749|access-date=December 14, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044836/https://books.google.com/books?id=zzMwBwAAQBAJ&pg=PA749|url-status=live}}</ref> However, most cervical cancers are [[asymptomatic]] (present no symptoms).<ref name="Daniels"/> Vaginal intracavity brachytherapy (VBT) is used to treat [[Endometrial cancer|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.<ref name=":1">{{Cite web|url=http://radonc.ucla.edu/gynecologic-brachytherapy-treatment|title=Cervical, Endometrial, Vaginal and Vulvar Cancers - Gynecologic Brachytherapy|website=radonc.ucla.edu|access-date=December 13, 2017|archive-date=December 14, 2017|archive-url=https://web.archive.org/web/20171214015448/http://radonc.ucla.edu/gynecologic-brachytherapy-treatment|url-status=live}}</ref><ref>{{Cite journal|vauthors=Sabater S, Andres I, Lopez-Honrubia V, Berenguer R, Sevillano M, Jimenez-Jimenez E, Rovirosa A, Arenas M |date=August 9, 2017 |title=Vaginal cuff brachytherapy in endometrial cancer – a technically easy treatment? |journal=Cancer Management and Research |volume=9|pages=351–362|doi=10.2147/CMAR.S119125|issn=1179-1322|pmc=5557121|pmid=28848362 |doi-access=free }}</ref> Survival rates increase with VBT when compared to external beam radiation therapy.<ref name=":1" /> 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.<ref>{{Cite journal |vauthors=Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W |date=January–February 2017 |title=American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review|journal=Brachytherapy|language=en|volume=16|issue=1|pages=95–108|doi=10.1016/j.brachy.2016.04.005|pmid=27260082 |pmc=5612425 }}</ref> Research is unclear on whether treating cervical cancer with radiation therapy increases the risk of vaginal cancer.<ref name="cancer.org2"/>
===Effects of aging and childbirth===
Age and hormone levels significantly correlate with the pH of the vagina.<ref name="Wilson">{{cite book|vauthors=Wilson M|title=Microbial Inhabitants of Humans: Their Ecology and Role in Health and Disease|publisher=[[Cambridge University Press]]|isbn=978-0-521-84158-0|year=2005|page=214|url=https://books.google.com/books?id=q9Qx9oRKO_kC&pg=PA214|access-date=January 14, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211238/https://books.google.com/books?id=q9Qx9oRKO_kC&pg=PA214|url-status=live}}</ref> Estrogen, glycogen and lactobacilli impact these levels.<ref name="Long"/><ref name="Mack"/> At birth, the vagina is acidic with a pH of approximately 4.5,<ref name="Wilson"/> and ceases to be acidic by three to six weeks of age,<ref name="Wilson 2">{{cite book|vauthors=Wilson CB, Nizet V, Maldonado Y, Remington JS, Klein JO|title=Remington and Klein's Infectious Diseases of the Fetus and Newborn E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-34096-0|year=2014|page=1053|url=https://books.google.com/books?id=W9b1BQAAQBAJ&pg=PA1053|access-date=January 14, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044743/https://books.google.com/books?id=W9b1BQAAQBAJ&pg=PA1053|url-status=live}}</ref> becoming alkaline.<ref name="Schafermeyer">{{cite book|vauthors=Schafermeyer RW, Tenenbein M, Macias CG, Sharieff G, Yamamoto L|title=Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition|publisher=[[McGraw Hill Professional]]|isbn=978-0-07-182924-3|year=2014|page=567}}</ref> Average vaginal pH is 7.0 in pre-pubertal girls.<ref name="Long">{{cite book|vauthors=Long SS, Prober CG, Fischer M|title=Principles and Practice of Pediatric Infectious Diseases E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-46132-0|year=2017|page=362|url=https://books.google.com/books?id=Xw7VDgAAQBAJ&pg=PA362|access-date=January 9, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211310/https://books.google.com/books?id=Xw7VDgAAQBAJ&pg=PA362|url-status=live}}</ref> 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&nbsp;cm. The vaginal mucosa thickens and the vaginal pH becomes acidic again. Girls may also experience a thin, white vaginal discharge called [[leukorrhea]].<ref name="Schafermeyer"/> The vaginal microbiota of adolescent girls aged 13 to 18 years is similar to women of reproductive age,<ref name="Mack">{{cite book|vauthors=Mack A, Olsen L, Choffnes ER|title=Microbial Ecology in States of Health and Disease: Workshop Summary|publisher=[[National Academies Press]]|isbn=978-0-309-29065-4|year=2014|page=252|url=https://books.google.com/books?id=wl-fAwAAQBAJ&pg=PT252|access-date=January 9, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211315/https://books.google.com/books?id=wl-fAwAAQBAJ&pg=PT252|url-status=live}}</ref> who have an average vaginal pH of 3.8–4.5,<ref name="King"/> but research is not as clear on whether this is the same for premenarcheal or perimenarcheal girls.<ref name="Mack"/> The vaginal pH during menopause is 6.5–7.0 (without [[Hormone replacement therapy (menopause)|hormone replacement therapy]]), or 4.5–5.0 with hormone replacement therapy.<ref name="Mack"/>
[[File:Vaginal Mucosa Normal vs Menopause.png|thumb|alt=Side-by-side illustration depicting thinning effects of menopause on musoca of vaginal wall|Pre-menopausal vaginal mucosa (left) versus menopausal vaginal mucosa (right)]]
After menopause, the body produces less estrogen. This causes [[atrophic vaginitis]] (thinning and inflammation of the vaginal walls),<ref name="Beckmann"/><ref name="Di Saia">{{cite book|vauthors=Di Saia PH|title=Clinical Gynecologic Oncology|publisher=Elsevier Health Sciences|isbn=978-0-323-07419-3|year=2012|page=140|url=https://books.google.com/books?id=fmUU5mNbH5kC&pg=PA140|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506163839/https://books.google.com/books?id=fmUU5mNbH5kC&pg=PA140|url-status=live}}</ref> which can lead to vaginal itching, burning, bleeding, soreness, or [[vaginal dryness]] (a decrease in lubrication).<ref name="Ward">{{cite book|vauthors=Ward S, Hisley S|title=Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families|publisher=[[F. A. Davis Company]]|isbn=978-0-8036-4490-8|pages=147–150|date=2015|url=https://books.google.com/books?id=XozHCQAAQBAJ&pg=RA1-PA147|access-date=August 13, 2017|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044842/https://books.google.com/books?id=XozHCQAAQBAJ&pg=RA1-PA147|url-status=live}}</ref> Vaginal dryness can cause discomfort on its own or discomfort or pain during sexual intercourse.<ref name="Ward"/><ref name="Schuiling">{{cite book|vauthors=Schuiling, Likis FE|title=Women's Gynecologic Health|publisher=[[Jones & Bartlett Publishers]]|isbn=978-0-7637-5637-6|page=305|date=2013|url=https://books.google.com/books?id=pj_ourS3PBMC&pg=PA305|access-date=January 9, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703215946/https://books.google.com/books?id=pj_ourS3PBMC&pg=PA305|url-status=live}}</ref> [[Hot flash]]es are also characteristic of menopause.<ref name="Leifer"/><ref name="Jones 2">{{cite book|vauthors=Jones RE, Davis KH|title=Human Reproductive Biology|publisher=[[Academic Press]]|isbn=978-0-12-382185-0|page=127|date=2013|url=https://books.google.com/books?id=M4kEdSnS-pkC&pg=PA127|access-date=August 13, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211321/https://books.google.com/books?id=M4kEdSnS-pkC&pg=PA127|url-status=live}}</ref> Menopause also affects the composition of vaginal support structures. The vascular structures become fewer with advancing age.<ref name="Mulhall 2">{{Cite book |page=19|title=Cancer and sexual health |date=2011|publisher=Humana Press|vauthors=Mulhall JP, Incrocci L, Goldstein I |isbn=978-1-60761-915-4|location=New York|oclc=728100149}}</ref>  Specific [[collagen]]s 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.<ref name="Walters">{{Cite book |title=Urogynecology and reconstructive pelvic surgery |vauthors=Walters MD, Karram MM |isbn=978-0-323-11377-9 |edition=4th |location=Philadelphia |publisher=Elsevier Saunders |date=2015 |pages=60–82 |oclc=894111717}}</ref>
Menopausal symptoms can be eased by estrogen-containing vaginal creams,<ref name="Jones 2"/> non-prescription, non-hormonal medications,<ref name="Ward"/> vaginal estrogen rings such as the [[Femring]],<ref name="Smith">{{cite book|vauthors=Smith BT|title=Pharmacology for Nurses|publisher=[[Jones & Bartlett Publishers]]|isbn=978-1-4496-8940-7|page=80|date=2014|url=https://books.google.com/books?id=7P-9BQAAQBAJ&pg=PA80|access-date=January 11, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043206/https://books.google.com/books?id=7P-9BQAAQBAJ&pg=PA80|url-status=live}}</ref> or other hormone replacement therapies,<ref name="Jones 2"/> but there are risks (including adverse effects) associated with hormone replacement therapy.<ref name="Greenstein">{{cite book|vauthors=Greenstein B, Greenstein A|title=Concise Clinical Pharmacology|publisher=[[Pharmaceutical Press]]|isbn=978-0-85369-576-9|page=186|date=2007|url=https://books.google.com/books?id=JM2vUhP6WAQC&pg=PA186|access-date=August 13, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211422/https://books.google.com/books?id=JM2vUhP6WAQC&pg=PA186|url-status=live}}</ref><ref name="Moscou">{{cite book|vauthors=Moscou K, Snipe K|title=Pharmacology for Pharmacy Technicians - E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-29265-8|page=573|date=2014|url=https://books.google.com/books?id=ZtHsAwAAQBAJ&pg=PA573|access-date=January 11, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704043201/https://books.google.com/books?id=ZtHsAwAAQBAJ&pg=PA573|url-status=live}}</ref> Vaginal creams and vaginal estrogen rings may not have the same risks as other hormone replacement treatments.<ref name="Gladson">{{cite book|vauthors=Gladson B|title=Pharmacology for Rehabilitation Professionals - E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-1-4377-0756-4|page=212|date=2010|url=https://books.google.com/books?id=6wgPsqi9nO8C&pg=PA212|access-date=January 11, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211236/https://books.google.com/books?id=6wgPsqi9nO8C&pg=PA212|url-status=live}}</ref> Hormone replacement therapy can treat vaginal dryness,<ref name="Smith"/> but a [[Personal lubricant#Vaginal lubricants|personal lubricant]] may be used to temporarily remedy vaginal dryness specifically for sexual intercourse.<ref name="Schuiling"/> Some women have an increase in sexual desire following menopause.<ref name="Ward"/> 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.<ref name="Ward"/> They may have less vaginal atrophy and fewer problems concerning sexual intercourse.<ref name="Lowdermilk">{{cite book|vauthors=Lowdermilk DL, Perry SE, Cashion MC, Alden KR|title=Maternity and Women's Health Care - E-Book|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-39019-4|year=2014|page=133|url=https://books.google.com/books?id=urzuBQAAQBAJ&pg=PA133|access-date=January 13, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044807/https://books.google.com/books?id=urzuBQAAQBAJ&pg=PA133|url-status=live}}</ref>
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 (pathology)|diastasis]] or disruption of the [[pubococcygeus muscle]]s caused by poor repair of an [[episiotomy]], and [[Bleb (medicine)|blebs]] that may protrude beyond the area of the vaginal opening.<ref name="Siemionow">{{cite book|vauthors=Siemionow MZ, Eisenmann-Klein M|title=Plastic and Reconstructive Surgery|publisher=[[Springer Science & Business Media]]|isbn=978-1-84882-513-0|pages=688–690|date=2010|url=https://books.google.com/books?id=9WFZ1pE0AFMC&pg=PA688|access-date=August 13, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211257/https://books.google.com/books?id=9WFZ1pE0AFMC&pg=PA688|url-status=live}}</ref> Other vaginal changes related to aging and childbirth are [[stress urinary incontinence]], [[rectocele]], and [[cystocele]].<ref name="Siemionow"/> 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.<ref name="Gulanick">{{cite book|vauthors=Gulanick M, Myers JL|title=Nursing Care Plans - E-Book: Nursing Diagnosis and Intervention|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-42810-1|year=2016|page=111|url=https://books.google.com/books?id=NK2ADQAAQBAJ&pg=PA111|access-date=January 13, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044804/https://books.google.com/books?id=NK2ADQAAQBAJ&pg=PA111|url-status=live}}</ref> [[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.<ref name="Ramaseshan">{{Cite journal|vauthors=Ramaseshan AS, Felton J, Roque D, Rao G, Shipper AG, Sanses T|date=September 19, 2017|title=Pelvic floor disorders in women with gynecologic malignancies: a systematic review|journal=International Urogynecology Journal|volume=29|issue=4|language=en|pages=459–476|doi=10.1007/s00192-017-3467-4|pmid=28929201|pmc=7329191|issn=0937-3462}}</ref><ref name="niddk_Cystocele">{{Cite news|url=https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/cystocele-prolapsed-bladder|title=Cystocele (Prolapsed Bladder) {{!}} NIDDK|work=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=January 15, 2018|language=en-US|archive-date=June 17, 2018|archive-url=https://web.archive.org/web/20180617092854/https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/cystocele-prolapsed-bladder|url-status=live}}</ref> A reduction in estrogen does not cause rectocele, cystocele or [[uterine prolapse]], but childbirth and weakness in pelvic support structures can.<ref name="Lowdermilk"/> Prolapse may also occur when the pelvic floor becomes injured during a [[hysterectomy]], gynecological cancer treatment, or heavy lifting.<ref name="Ramaseshan"/><ref name="niddk_Cystocele"/> Pelvic floor exercises such as [[Kegel exercise]]s can be used to strengthen the pelvic floor muscles,<ref>{{Cite news|url=https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/kegel-exercises|title=Kegel Exercises {{!}} NIDDK|work=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=January 15, 2018|language=en-US|archive-date=April 22, 2018|archive-url=https://web.archive.org/web/20180422224842/https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/kegel-exercises|url-status=live}}</ref> preventing or arresting the progression of prolapse.<ref name="pmid22161382">{{cite journal |vauthors=Hagen S, Stark D |s2cid=205171605 |title=Conservative prevention and management of pelvic organ prolapse in women |journal=Cochrane Database Syst Rev |volume=12 |issue=12 |pages=CD003882 |year=2011 |pmid=22161382 |doi=10.1002/14651858.CD003882.pub4 }}</ref> There is no evidence that doing Kegel exercises [[Isotonic contraction|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.<ref>{{cite journal|vauthors=Herbison GP, Dean N|title=Weighted vaginal cones for urinary incontinence|journal=The Cochrane Database of Systematic Reviews|date=July 8, 2013|volume=2013 |issue=7|pages=CD002114|pmid=23836411|doi=10.1002/14651858.CD002114.pub2 |doi-access=free |pmc=7086390}}</ref>
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.<ref name="Dalton" /><ref name=":2" /> The laceration can be so extensive as to involve the rectum and [[Human anus|anus]]. This event can be especially distressing to a new mother.<ref name=":2" /><ref>{{Cite journal|vauthors=Kettle C|date=August 2010|title=Absorbable suture materials for primary repair of episiotomy and second degree tears|journal=Journal of Evidence-Based Medicine|language=en|volume=3|issue=3|pages=185|doi=10.1111/j.1756-5391.2010.01093.x |doi-access=free |pmid=20556745|pmc=7263442|issn=1756-5391|url=http://eprints.staffs.ac.uk/268/1/CD000006.pdf|access-date=December 3, 2019|archive-date=August 18, 2019|archive-url=https://web.archive.org/web/20190818225808/http://eprints.staffs.ac.uk/268/1/CD000006.pdf|url-status=live}}</ref> When this occurs, [[fecal incontinence]] develops and stool can leave through the vagina.<ref name=":2">{{Cite book |title=Maternal-newborn Nursing: The Critical Components of Nursing Care |publisher=F.A. Davis |vauthors=Durham R, Chapman L |year=2014|isbn=978-0-8036-3704-7|edition=2nd |location=Philadelphia|pages=212–213|oclc=829937238}}</ref> Close to 85% of [[spontaneous vaginal birth]]s develop some form of tearing. Out of these, 60–70% require [[suturing]].<ref name="kettle_et_al_2017">{{Cite journal |title=Comparative analysis of continuous and interrupted suturing techniques for repair of episiotomy or second degree perineal tear|journal=Cochrane Database of Systematic Reviews |volume=2012 |vauthors=Kettle C, Dowswell T, Ismail KM |year=2017|issue=11 |pages=CD000947|language=en|doi=10.1002/14651858.cd000947.pub3|pmid=23152204 |pmc=7045987 }}</ref><ref name="Fernando">{{Cite journal |vauthors=Fernando R |s2cid=219223164 |date=January 2011 |title=Episiotomy or perineal tears: compared with catgut, synthetic sutures reduce risk of short-term pain and need for resuturing; rapidly absorbing sutures comparable to synthetic but reduce the need for suture removal |journal=Evidence-Based Nursing|language=en|volume=14|issue=1|pages=17–18|doi=10.1136/ebn1110|issn=1367-6539|pmid=21163794}}</ref> Lacerations from labor do not always occur.<ref name="Anderson" />
===Surgery===
The vagina, including the vaginal opening, may be altered as a result of surgeries such as an episiotomy, [[vaginectomy]], [[vaginoplasty]] or [[labiaplasty]].<ref name="Siemionow"/><ref name=Tabers>{{cite book|vauthors=Venes D|title=Taber's Cyclopedic Medical Dictionary|url=https://archive.org/details/taberscyclopedic00vene_746|url-access=limited|publisher=F.A. Davis|isbn=978-0-8036-2977-6|year=2009|page=[https://archive.org/details/taberscyclopedic00vene_746/page/n2467 2433]}}</ref> Those who undergo vaginoplasty are usually older and have given birth.<ref name="Siemionow"/> A thorough examination of the vagina before a vaginoplasty is standard, as well as a referral to a [[urogynecologist]] to diagnose possible vaginal disorders.<ref name="Siemionow"/> 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.<ref name="Siemionow"/>
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.<ref name="Anderson" /><ref name=":1" /> Although its routine use is no longer recommended,<ref name=ACOG165>{{cite journal|title=Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery.|journal=Obstetrics and Gynecology|date=July 2016|volume=128|issue=1|pages=e1–e15|pmid=27333357|doi=10.1097/AOG.0000000000001523|author1=American College of Obstetricians Gynecologists' Committee on Practice Bulletins—Obstetrics|s2cid=20952144}}</ref> and not having an episiotomy is found to have better results than an episiotomy,<ref name="Anderson" /> 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.<ref name="medline_482">{{Cite web |url=https://medlineplus.gov/ency/patientinstructions/000482.htm |title=Episiotomy: MedlinePlus Medical Encyclopedia |website=Medlineplus.gov |language=en |access-date=December 13, 2017 |archive-date=December 14, 2017 |archive-url=https://web.archive.org/web/20171214072136/https://medlineplus.gov/ency/patientinstructions/000482.htm |url-status=live }}</ref><ref name = "Ellis">{{Cite book |vauthors=Ellis H, Mahadevan V |title=Clinical anatomy : applied anatomy for students and junior doctors |date=2013 |publisher=Wiley-Blackwell |isbn=978-1-118-37377-4|edition=13th |location=Chichester, West Sussex, UK |pages=148 |oclc=856017698}}</ref> Episiotomies can be painful after delivery. Women often report pain during sexual intercourse up to three months after laceration repair or an episiotomy.<ref name="kettle_et_al_2017"/><ref name="Fernando"/> Some surgical techniques result in less pain than others.<ref name="kettle_et_al_2017"/> 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.<ref name="Anderson" /><ref>{{Cite journal |vauthors=Verghese TS, Champaneria R, Kapoor DS, Latthe PM |date=October 2016 |title=Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis |journal=International Urogynecology Journal|language=en|volume=27|issue=10|pages=1459–1467|doi=10.1007/s00192-016-2956-1|pmid=26894605 |issn=0937-3462|pmc=5035659}}</ref> 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.<ref name="Anderson" />
Vaginectomy is surgery to remove all or part of the vagina, and is usually used to treat malignancy.<ref name=Tabers/> Removal of some or all of the sexual organs can result in damage to the nerves and leave behind scarring or [[Adhesion (medicine)|adhesions]].<ref name="Holland">{{cite book|title=Psycho-oncology|vauthors=Holland JC, Breitbart WD, Jacobsen PB|publisher=[[Oxford University Press]]|year=2015|isbn=978-0-19-936331-5|page=220|url=https://books.google.com/books?id=oy9mBgAAQBAJ&pg=PA220|access-date=December 12, 2017|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211443/https://books.google.com/books?id=oy9mBgAAQBAJ&pg=PA220|url-status=live}}</ref> 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.<ref name="Holland"/>
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.<ref name="Goodman">{{cite book|title=Female Genital Plastic and Cosmetic Surgery|vauthors=Goodman, MP|publisher=[[John Wiley & Sons]]|year=2016|isbn=978-1-118-84848-7|page=287|url=https://books.google.com/books?id=RJ-ECwAAQBAJ&pg=PT287|access-date=January 4, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044746/https://books.google.com/books?id=RJ-ECwAAQBAJ&pg=PT287|url-status=live}}</ref> While a woman may experience an improvement in [[self-image]] and sexual pleasure by undergoing vaginal tightening or rejuvenation,<ref name="Goodman"/> there are risks associated with the procedures, including infection, narrowing of the vaginal opening, insufficient tightening, decreased sexual function (such as [[Dyspareunia|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.<ref name="Cardozo">{{cite book|url=https://books.google.com/books?id=Bb7ZDQAAQBAJ&pg=PT2962|title=Textbook of Female Urology and Urogynecology, Fourth Edition - Two-Volume Set|vauthors=Cardozo L, Staskin D|publisher=[[CRC Press]]|year=2017|isbn=978-1-4987-9661-3|pages=2962–2976|access-date=January 4, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044737/https://books.google.com/books?id=Bb7ZDQAAQBAJ&pg=PT2962|url-status=live}}</ref>
===Anomalies and other health issues===
{{See also|Vaginal atresia}}
[[File:Vagina US.png|right|thumb|alt=Ultrasonograph depicting urinary bladder at the top, above the uterus to its bottom-left and vagina to its bottom-right|An [[Medical ultrasonography|ultrasound]] showing the [[urinary bladder]] (1), uterus (2), and vagina (3)]]
[[Vaginal anomalies]] are defects that result in an abnormal or absent vagina.<ref name= emed2>{{Cite web |date=April 13, 2016 |author=Lawrence S Amesse |title=Mullerian Duct Anomalies: Overview, Incidence and Prevalence, Embryology |url=https://emedicine.medscape.com/article/273534-overview#a4 |access-date=January 31, 2018 |archive-url=https://web.archive.org/web/20180120070642/https://emedicine.medscape.com/article/273534-overview |archive-date=2018-01-20 |url-status=live}}</ref><ref>{{Cite web|url=http://www.merckmanuals.com/professional/pediatrics/congenital-renal-and-genitourinary-anomalies/vaginal-anomalies|title=Vaginal Anomalies-Pediatrics-Merck Manuals Professional Edition|access-date=January 6, 2018|archive-date=January 29, 2019|archive-url=https://web.archive.org/web/20190129072510/https://www.merckmanuals.com/professional/pediatrics/congenital-renal-and-genitourinary-anomalies/vaginal-anomalies|url-status=live}}</ref> The most common obstructive vaginal anomaly is an [[imperforate hymen]], a condition in which the hymen obstructs menstrual flow or other vaginal secretions.<ref name="Pfeifer">{{cite book|vauthors=Pfeifer SM|title=Congenital Müllerian Anomalies: Diagnosis and Management|publisher=[[Springer Publishers|Springer]]|isbn=978-3-319-27231-3|year=2016|pages=43–45|url=https://books.google.com/books?id=7TyVDAAAQBAJ&pg=PA43|access-date=January 31, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703215939/https://books.google.com/books?id=7TyVDAAAQBAJ&pg=PA43|url-status=live}}</ref><ref name="Zhu">{{cite book|vauthors=Zhu L, Wong F, Lang J|title=Atlas of Surgical Correction of Female Genital Malformation|publisher=[[Springer Publishers|Springer]]|isbn=978-94-017-7246-4|year=2015|page=18|url=https://books.google.com/books?id=-l54CgAAQBAJ&pg=PA18|access-date=April 2, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211243/https://books.google.com/books?id=-l54CgAAQBAJ&pg=PA18|url-status=live}}</ref> Another vaginal anomaly is a [[transverse vaginal septum]], which partially or completely blocks the vaginal canal.<ref name="Pfeifer"/> The precise cause of an obstruction must be determined before it is repaired, since corrective surgery differs depending on the cause.<ref name="Coran">{{cite book|vauthors=Coran AG, Caldamone A, Adzick NS, Krummel TM, Laberge JM, Shamberger R|title=Pediatric Surgery|publisher=[[Elsevier Health Sciences]]|isbn=978-0-323-09161-9|year=2012|page=1599|url=https://books.google.com/books?id=QpabASTwF_sC&pg=PA1599|access-date=March 4, 2015|archive-date=May 15, 2015|archive-url=https://web.archive.org/web/20150515033701/https://books.google.com/books?id=QpabASTwF_sC&pg=PA1599|url-status=live}}</ref> In some cases, such as isolated [[vaginal agenesis]], the external genitalia may appear normal.<ref name="Nucci">{{cite book|vauthors=Nucci MR, Oliva E|title=Gynecologic Pathology E-Book: A Volume in the Series: Foundations in Diagnostic Pathology|publisher=[[Elsevier Health Sciences]]|isbn=978-94-017-7246-4|year=2015|page=77|url=https://books.google.com/books?id=7fbLXoJy9MUC&pg=PA77|access-date=April 2, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211232/https://books.google.com/books?id=7fbLXoJy9MUC&pg=PA77|url-status=live}}</ref>
Abnormal openings known as [[fistula]]s can cause [[urine]] or [[Human feces|feces]] to enter the vagina, resulting in incontinence.<ref name="Bodner-Adler">{{cite journal|date=February 22, 2017 |title=Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis|journal=PLOS ONE|volume=12|issue=2|pages=e0171554|doi=10.1371/journal.pone.0171554|pmid=28225769|pmc=5321457|vauthors=Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K|bibcode=2017PLoSO..1271554B|doi-access=free}}</ref><ref name="Köckerling">{{cite journal|date=2015|title=Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique|journal=Frontiers in Surgery|volume=2|pages=55|doi=10.3389/fsurg.2015.00055|pmid=26528482|pmc=4607815|vauthors=Köckerling F, Alam NN, Narang SK, Daniels IR, Smart NJ|doi-access=free}}</ref> The vagina is susceptible to fistula formation because of its proximity to the [[Urinary tract|urinary]] and [[Gastrointestinal tract|gastrointestinal]] tracts.<ref name="Priyadarshi">{{cite journal|date=June 2016|title=Genitourinary Fistula: An Indian Perspective|journal=Journal of Obstetrics and Gynaecology of India|volume=66|issue=3|pages=180–4|doi=10.1007/s13224-015-0672-2|pmc=4870662|pmid=27298528|vauthors=Priyadarshi V, Singh JP, Bera MK, Kundu AK, Pal DK}}</ref> Specific causes are manifold and include obstructed labor, hysterectomy, [[malignancy]], radiation, [[episiotomy]], and bowel disorders.<ref name="Raassen">{{cite journal|date=December 2014|title=Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries|journal=International Urogynecology Journal|language=en|volume=25|issue=12|pages=1699–706|doi=10.1007/s00192-014-2445-3|pmid=25062654|vauthors=Raassen TJ, Ngongo CJ, Mahendeka MM|pmc=4234894}}</ref><ref name="Maslekar">{{cite journal|date=December 2012|title=The challenge of pouch-vaginal fistulas: a systematic review|journal=Techniques in Coloproctology|volume=16|issue=6|pages=405–14|doi=10.1007/s10151-012-0885-7|pmid=22956207|vauthors=Maslekar S, Sagar PM, Harji D, Bruce C, Griffiths B|s2cid=22813363}}</ref> A small number of vaginal fistulas are [[congenital]].<ref name="Fernandez">{{cite journal|date=September 2015|title=Congenital recto-vaginal fistula associated with a normal anus (type H fistula) and rectal atresia in a patient. Report of a case and a brief review of the literature |journal=Investigacion Clinica|volume=56|issue=3|pages=301–7|pmid=26710545|vauthors=Fernández Fernández JÁ, Parodi Hueck L}}</ref> Various surgical methods are employed to repair fistulas.<ref name="Tenggardjaja">{{cite journal | vauthors = Tenggardjaja CF, Goldman HB | s2cid = 27012043 | title = Advances in minimally invasive repair of vesicovaginal fistulas | language = en | journal = Current Urology Reports | volume = 14 | issue = 3 | pages = 253–61 | date = June 2013 | pmid = 23475747 | doi = 10.1007/s11934-013-0316-y }}</ref><ref name="Bodner-Adler" /> Untreated, fistulas can result in significant [[disability]] and have a profound impact on [[quality of life]].<ref name="Bodner-Adler"/>
[[Vaginal evisceration]] is a serious complication of a [[vaginal hysterectomy]] and occurs when the [[vaginal cuff]] [[Wound dehiscence|ruptures]], allowing the [[small intestine]] to protrude from the vagina.<ref name="Hoffman" /><ref name="Cronin">{{Cite journal|date=April 2012|title=Vaginal cuff dehiscence: Risk factors and management|journal=American Journal of Obstetrics and Gynecology|volume=206|issue=4|pages=284–288|doi=10.1016/j.ajog.2011.08.026|issn=0002-9378|pmc=3319233|pmid=21974989|doi-access=free|vauthors=Cronin B, Sung V, Matteson K}}</ref>
[[Cyst]]s 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&nbsp;cm.<ref name=lall>{{Cite journal |vauthors=Lallar M, Nandal R, Sharma D, Shastri S |date=January 20, 2015 |title=Large posterior vaginal cyst in pregnancy|journal=BMJ Case Reports|volume=2015|pages=bcr2014208874 |doi=10.1136/bcr-2014-208874|issn=1757-790X|pmc=4307045|pmid=25604504}}</ref><ref>{{Cite web|url=https://medlineplus.gov/ency/article/001509.htm|title=Vaginal cysts: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=February 17, 2018|archive-date=November 2, 2020|archive-url=https://web.archive.org/web/20201102003330/https://medlineplus.gov/ency/article/001509.htm|url-status=live}}</ref> Often, they are an incidental finding during a routine pelvic examination.<ref name=":0">{{Cite journal |vauthors=Elsayes KM, Narra VR, Dillman JR, Velcheti V, Hameed O, Tongdee R, Menias CO |s2cid=31444644|date=October 2007|title=Vaginal masses: magnetic resonance imaging features with pathologic correlation|journal=Acta Radiologica  |volume=48|issue=8|pages=921–933|doi=10.1080/02841850701552926|issn=1600-0455|pmid=17924224}}</ref> Vaginal cysts can mimic other structures that protrude from the vagina such as a rectocele and cystocele.<ref name=lall/> Cysts that can be present include [[Müllerian cyst]]s, [[Gartner's duct cyst]]s, and [[epidermoid cyst]]s.<ref name=":4">{{Cite book|url=https://books.google.com/books?id=TYlZsGdwqrQC&q=Vaginal+cyst&pg=PA220|title=Gynecology: Integrating Conventional, Complementary, and Natural Alternative Therapy|vauthors=Ostrzenski A|date=2002|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2761-7|language=en|access-date=October 19, 2020|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000717/https://books.google.com/books?id=TYlZsGdwqrQC&q=Vaginal+cyst&pg=PA220|url-status=live}}</ref><ref>{{cite journal|vauthors=Hoogendam JP, Smink M |date=April 6, 2017|title=Gartner's Duct Cyst|journal=New England Journal of Medicine|volume=376|issue=14|pages=e27|doi=10.1056/NEJMicm1609983|pmid=28379795}}</ref> A vaginal cyst is most likely to develop in women between the ages of 30 and 40.<ref name=lall/> It is estimated that 1 out of 200 women has a vaginal cyst.<ref name= lall/><ref name="Marisa R.">{{Cite book|url=https://books.google.com/books?id=r7EOW0jm2CoC&q=Vaginal+cyst&pg=PA96|title=Gynecologic Pathology|vauthors=Nucci MR, Oliva E|date=January 1, 2009|publisher=Elsevier Health Sciences|isbn=978-0-443-06920-8|pages=96|language=en|access-date=October 19, 2020|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000420/https://books.google.com/books?id=r7EOW0jm2CoC&q=Vaginal+cyst&pg=PA96|url-status=live}}</ref> The [[Bartholin's cyst]] is of vulvar rather than vaginal origin,<ref name="Robboy 2">{{cite book|vauthors=Robboy SJ|title=Robboy's Pathology of the Female Reproductive Tract|publisher=[[Elsevier Health Sciences]]|isbn=978-0-443-07477-6|year=2009|page=117|url=https://books.google.com/books?id=ab545XL-MBEC&pg=PA117|access-date=March 8, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703220034/https://books.google.com/books?id=ab545XL-MBEC&pg=PA117|url-status=live}}</ref> but it presents as a lump at the vaginal opening.<ref name="Marx">{{cite book|vauthors=Marx J, Walls R, Hockberger R|title=Rosen's Emergency Medicine - Concepts and Clinical Practice|publisher=[[Elsevier Health Sciences]]|isbn=978-1-4557-4987-4|year=2013|page=1314|url=https://books.google.com/books?id=uggC0i_jXAsC&pg=PA1314|access-date=February 24, 2015|archive-date=May 15, 2015|archive-url=https://web.archive.org/web/20150515033915/https://books.google.com/books?id=uggC0i_jXAsC&pg=PA1314|url-status=live}}</ref> It is more common in younger women and is usually without symptoms,<ref name="Cash">{{cite book|vauthors=Cash JC, Glass CA|title=Sternberg's Diagnostic Surgical Pathology, Volume 1|publisher=[[Springer Publishing Company]]|isbn=978-0-8261-5351-7|year=2017|page=425|url=https://books.google.com/books?id=9tRJDwAAQBAJ&pg=PA425|access-date=February 15, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211347/https://books.google.com/books?id=9tRJDwAAQBAJ&pg=PA425|url-status=live}}</ref> but it can cause pain if an [[abscess]] forms,<ref name="Cash"/> block the entrance to the [[vulval vestibule]] if large,<ref name="Sternberg">{{cite book|vauthors=Sternberg SS, Mills SE, Carter D|title=Sternberg's Diagnostic Surgical Pathology, Volume 1|publisher=[[Lippincott Williams & Wilkins]]|isbn=978-0-7817-4051-7|year=2004|page=2335|url=https://books.google.com/books?id=TM5-h0Fo9_4C&pg=PA2335|access-date=February 15, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044848/https://books.google.com/books?id=TM5-h0Fo9_4C&pg=PA2335|url-status=live}}</ref> and impede walking or cause painful sexual intercourse.<ref name="Cash"/>
==Society and culture==
{{see also|Vulva#Society and culture}}
===Perceptions, symbolism and vulgarity===
{{See also|Eurotophobia}}
The word ''vagina'' is commonly avoided in conversation,<ref name="Blackledge">{{cite book|vauthors=Blackledge C |title=The Story of V: A Natural History of Female Sexuality |publisher=[[Rutgers University Press]]|pages=[https://archive.org/details/storyofv00cath/page/4 4]–5|isbn=978-0-8135-3455-8|year=2003 |url=https://archive.org/details/storyofv00cath|url-access=registration }}</ref> and many people are confused about the vagina's anatomy and may be unaware that it is not used for urination.<ref name="Rosenthal2">{{cite book|vauthors=Rosenthal MS |title=Gynecological Health : a Comprehensive Sourcebook for Canadian Women |publisher=[[Viking Canada]]|page=10|isbn=978-0-670-04358-3|year=2003 |quote=The urine flows from the bladder through the urethra to the outside. Little girls often make the common mistake of thinking that they're urinating out of their vaginas. A woman's urethra is two inches long, while a man's is ten inches long.}}</ref><ref name="Hickling">{{cite book |vauthors=Hickling M |title=The New Speaking of Sex: What Your Children Need to Know and When They Need to Know It |publisher=Wood Lake Publishing |page=149 |isbn=978-1-896836-70-6 |year=2005 |url=https://books.google.com/books?id=3sHjkajLrsQC&pg=PT149 |access-date=October 27, 2015 |archive-date=April 29, 2016 |archive-url=https://web.archive.org/web/20160429141851/https://books.google.com/books?id=3sHjkajLrsQC&pg=PT149 |url-status=live }}</ref><ref name="Rankin">{{cite book |vauthors=Rankin L |title=Sex, Orgasm, and Coochies: A Gynecologist Answers Your Most Embarrassing Questions |publisher=[[Macmillan Publishers|Macmillan]] |page=22 |isbn=978-1-4299-5522-5 |year=2011 |url=https://books.google.com/books?id=Qs_dBty7pfcC&pg=PT22 |access-date=October 27, 2015 |archive-date=May 6, 2016 |archive-url=https://web.archive.org/web/20160506170754/https://books.google.com/books?id=Qs_dBty7pfcC&pg=PT22 |url-status=live }}</ref> 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.<ref name="Hickling"/> 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.<ref name="Hutcherson"/> Scholar {{ill|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.<ref name="Blackledge"/>
[[File:Cattien stone yoni.png|thumb|right|upright=0.91|alt=Photograph of a large stone yoni in a museum display case|The womb represents a powerful symbol as the ''[[yoni]]'' in [[Hinduism]]. Pictured is a stone yoni found in Cát Tiên sanctuary, Lam Dong, Vietnam.]]
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".<ref name="Linn">{{cite book|vauthors=Linn D|title=Secret Language of Signs|publisher=[[Random House|Random House Publishing Group]]|page=276|isbn=978-0-307-55955-5|year=2009|url=https://books.google.com/books?id=YB5_AT_By6IC&pg=PA276|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506171852/https://books.google.com/books?id=YB5_AT_By6IC&pg=PA276|url-status=live}}</ref> [[Sigmund Freud]] placed significant value on the vagina,<ref name="Laqueur">{{cite book|vauthors=Laqueur TW|title=Making Sex: Body and Gender from the Greeks to Freud|publisher=[[Harvard University Press]]|page=236|isbn=978-0-674-54355-3|year=1992|url=https://books.google.com/books?id=XR2BcRwiG-sC&pg=PA236|access-date=October 27, 2015|archive-date=May 7, 2016|archive-url=https://web.archive.org/web/20160507064737/https://books.google.com/books?id=XR2BcRwiG-sC&pg=PA236|url-status=live}}</ref> 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.<ref name="Zastrow">{{cite book |vauthors=[[Charles Zastrow|Zastrow C]] |title=Introduction to Social Work and Social Welfare: Empowering People |publisher=[[Cengage Learning]] |year=2007 |page=228 |isbn=978-0-495-09510-1 |url=https://books.google.com/books?id=tco4YjyZab4C&pg=PT248 |access-date=October 27, 2015 |archive-date=October 23, 2020 |archive-url=https://web.archive.org/web/20201023063416/https://books.google.com/books?id=tco4YjyZab4C&pg=PT248 |url-status=live }}</ref><ref name="Irvine">{{cite book|vauthors=Irvine JM|title=Disorders of Desire: Sexuality and Gender in Modern American Sexology|isbn=978-1-59213-151-8|publisher=Temple University Press|year=2005|pages=37–38|url=https://books.google.com/books?id=uIJXT7ZCTCsC&pg=PA37|access-date=August 20, 2020|archive-date=April 29, 2016|archive-url=https://web.archive.org/web/20160429140257/https://books.google.com/books?id=uIJXT7ZCTCsC&pg=PA37|url-status=live}}</ref><ref name="Gould">{{cite book |vauthors=[[Stephen Jay Gould|Gould SJ]] |title=The Structure of Evolutionary Theory |publisher=[[Harvard University Press]] |year=2002 |pages=1262–1263 |isbn=978-0-674-00613-3 |url=https://books.google.com/books?id=nhIl7e61WOUC&pg=PA767 |access-date=August 20, 2020 |archive-date=May 27, 2016 |archive-url=https://web.archive.org/web/20160527015618/https://books.google.com/books?id=nhIl7e61WOUC&pg=PA767 |url-status=live }}</ref> 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;<ref name="Wignaraja">{{cite book|vauthors=Wignaraja P, Hussain A|title=The Challenge in South Asia: Development, Democracy and Regional Cooperation|publisher=[[United Nations University Press]]|page=309|isbn=978-0-8039-9603-8|year=1989|url=https://books.google.com/books?id=Y9DmV9-0on0C&pg=PA309|access-date=October 27, 2015|archive-date=May 7, 2016|archive-url=https://web.archive.org/web/20160507064652/https://books.google.com/books?id=Y9DmV9-0on0C&pg=PA309|url-status=live}}</ref> however, ''yoni'' as a representation of "womb" is not the primary denotation.<ref name="lochtefeld784">{{Cite book |last=Lochtefeld |first=James G. |url=https://books.google.com/books?id=g6FsB3psOTIC&pg=PA784 |title=The Illustrated Encyclopedia of Hinduism, Volume 2 |publisher=The Rosen Publishing Group |year=2001 |isbn=978-0-8239-3180-4 |page=784 |access-date=September 13, 2021 |archive-date=June 2, 2019 |archive-url=https://web.archive.org/web/20190602132447/https://books.google.com/books?id=g6FsB3psOTIC |url-status=live }}</ref>
While, in ancient times, the vagina was often considered equivalent ([[Homology (biology)|homologous]]) to the penis, with anatomists [[Galen]] (129 AD&nbsp;– 200 AD) and [[Andreas Vesalius|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.<ref name="O'Connell"/><ref name="Angier">{{cite book |vauthors=[[Natalie Angier|Angier N]] |title=Woman: An Intimate Geography |publisher=[[Houghton Mifflin Harcourt]]|page=[https://archive.org/details/womanintimategeo00angi_0/page/92 92]|isbn=978-0-395-69130-4 |year=1999 |url=https://archive.org/details/womanintimategeo00angi_0|url-access=registration}}</ref> 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 {{lang|la|suffocatio ex semine retento}} (suffocation of the womb, {{literal translation|lk=on}}&nbsp;'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&nbsp;– a concept that is no longer recognized by medical authorities as a medical disorder&nbsp;– 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.<ref name=Maines>{{cite book |vauthors=Maines RP |title=The Technology of Orgasm: "Hysteria", the Vibrator, and Women's Sexual Satisfaction |publisher=The Johns Hopkins University Press |location=Baltimore |year=1998 |pages=1–188 |isbn=978-0-8018-6646-3 |url=https://books.google.com/books?id=iNKw0XuaSxoC |access-date=December 12, 2017 |archive-date=July 3, 2019 |archive-url=https://web.archive.org/web/20190703221610/https://books.google.com/books?id=iNKw0XuaSxoC |url-status=live }}</ref> It may be that women who were considered suffering from female hysteria condition would sometimes undergo "pelvic massage"&nbsp;– 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.<ref name=Maines/>
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.<ref name="Hughes">{{cite book |vauthors=Hughes G |title=An Encyclopedia of Swearing: The Social History of Oaths, Profanity, Foul Language, and Ethnic Slurs in the English-speaking World |publisher=[[Routledge]] |isbn=978-1-317-47678-8 |year=2015 |page=112 |url=https://books.google.com/books?id=sIGsBwAAQBAJ&pg=PA112 |access-date=December 12, 2017 |archive-date=July 3, 2019 |archive-url=https://web.archive.org/web/20190703213021/https://books.google.com/books?id=sIGsBwAAQBAJ&pg=PA112 |url-status=live }}</ref> Reflecting [[List of dialects of the English language|different national usages]], ''cunt'' is described as "an unpleasant or stupid person" in the ''[[Compact Oxford English Dictionary of Current English|Compact Oxford English Dictionary]]'',<ref name="Compact">{{cite encyclopedia |year=2008 |title=cunt |dictionary=Compact Oxford English Dictionary of Current English|edition=3rd (revised) |publisher=Oxford University Press |location=Oxford}}</ref> whereas the [[Merriam-Webster]] has a usage of the term as "usually disparaging and obscene: woman",<ref>{{cite web|title=Definition of CUNT|publisher=[[Merriam-Webster]]|access-date=June 9, 2014|url=http://www.merriam-webster.com/dictionary/cunt|website=Dictionary – Merriam-Webster online|archive-date=October 22, 2012|archive-url=https://web.archive.org/web/20121022230104/http://www.merriam-webster.com/dictionary/cunt|url-status=live}}</ref> noting that it is used in the United States as "an offensive way to refer to a woman".<ref>{{cite web|title=cunt|url=http://www.learnersdictionary.com/search/cunt|website=Merriam-Webster's Learner's Dictionary|publisher=Merriam-Webster|access-date=September 13, 2013|archive-date=March 23, 2013|archive-url=https://web.archive.org/web/20130323233128/http://www.learnersdictionary.com/search/cunt|url-status=dead}}</ref> ''[[Random House Webster's Unabridged Dictionary|Random House]]'' defines it as "a despicable, contemptible or foolish man".<ref name="Hughes"/> Some [[feminist]]s of the 1970s sought to eliminate disparaging terms such as ''cunt''.<ref>{{cite book |vauthors=Johnston H, Klandermans B |title=Social Movements and Culture |publisher=Routledge |year=1995 |page=174 |isbn=978-1-85728-500-0}}</ref> ''Twat'' is widely used as a derogatory epithet, especially in [[British English]], referring to a person considered obnoxious or stupid.<ref name="dict">{{cite web |title=Twat |website=Dictionary.com |date=2015 |url=http://www.dictionary.com/browse/twat?s=t |access-date=June 16, 2015 |archive-date=January 23, 2017 |archive-url=https://web.archive.org/web/20170123154204/http://www.dictionary.com/browse/twat?s=t |url-status=live }} This source aggregates material from paper dictionaries, including ''Random House Dictionary'', ''Collins English Dictionary'', and Harper's ''Online Etymology Dictionary''.</ref><ref name="oxford dic">{{cite web|title=Definition of twat in English|url=http://www.oxforddictionaries.com/us/definition/english/twat|website=Oxford Dictionaries|at=British and World English lexicon|publisher=Oxford University Press|access-date=June 16, 2015|archive-date=June 4, 2015|archive-url=https://web.archive.org/web/20150604082811/http://www.oxforddictionaries.com/us/definition/english/twat|url-status=dead}}</ref> ''Pussy'' can indicate "[[cowardice]] or [[weakness]]", and "the human vulva or vagina" or by extension "sexual intercourse with a woman".<ref name="OED 1">{{cite encyclopedia |year=2007 |title =pussy, ''n''. and ''adj''.<sup>2</sup> |dictionary=Oxford English Dictionary |edition=3rd |publisher=Oxford University Press |location=Oxford}}</ref> In English, the use of the word ''pussy'' to refer to women is considered derogatory or demeaning, treating people as sexual objects.<ref>{{Cite journal|vauthors=James D |title=Gender-linked derogatory terms and their use by women and men |journal=American Speech |volume=73 |issue=4 |pages=399–420 |date=Winter 1998 |doi=10.2307/455584 |jstor=455584 }}</ref>
===In literature and art===
{{Main|Vagina and vulva in art}}
The ''[[vagina loquens]]'', or "talking vagina", is a significant tradition in literature and art, dating back to the ancient [[folklore]] [[Motif (folkloristics)|motifs]] of the "talking cunt".<ref name=ozark>{{cite book|title=Unprintable Ozark Folksongs and Folklore: Blow the candle out|publisher=[[University of Arkansas Press]]|vauthors=Randolph V, Legman G|year=1992|url=https://books.google.com/books?id=S93LdPw2KP0C|isbn=978-1-55728-237-8|pages=819–820|access-date=August 20, 2020|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000549/https://books.google.com/books?id=S93LdPw2KP0C|url-status=live}}</ref><ref name=Zizek>{{cite book|title=Organs without bodies: Deleuze and consequences|publisher=[[Routledge]]|vauthors=Zizek S|year=2004|url=https://books.google.com/books?id=Pp6-1yQbgmgC|isbn=978-0-415-96921-5|page=173|access-date=August 20, 2020|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000303/https://books.google.com/books?id=Pp6-1yQbgmgC|url-status=live}}</ref> These tales usually involve vaginas talking by the effect of magic or charms, and often admitting to their lack of [[chastity]].<ref name=ozark/> 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 tale]]s warning of the dangers of unknown women and to discourage [[rape]].<ref name=WhatsUp>{{cite book |isbn=978-0-312-64436-9 |url=https://books.google.com/books?id=2ybaNhKqGmwC&pg=PA59 |title=What's Up Down There?: Questions You'd Only Ask Your Gynecologist If She Was Your Best Friend |publisher=[[St. Martin's Press]] |date=2010 |page=59 |vauthors=Rankin L |access-date=August 20, 2020 |archive-date=March 10, 2021 |archive-url=https://web.archive.org/web/20210310000301/https://books.google.com/books?id=2ybaNhKqGmwC&pg=PA59 |url-status=live }}</ref>
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 {{lang|sv|"hon-en katedral"|italic=unset}} (also spelled {{lang|sv|"Hon-en-Katedrall"|italic=unset}}, 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.<ref>{{cite web|title=Life & Work|publisher=nikidesaintphalle.org|date=2017|access-date=November 8, 2014|url=http://nikidesaintphalle.org/niki-de-saint-phalle/biography/#1965-1969|archive-date=November 4, 2016|archive-url=https://web.archive.org/web/20161104232128/http://nikidesaintphalle.org/niki-de-saint-phalle/biography/#1965-1969|url-status=dead}}</ref>
===Influence on modification===
{{See also|Genital modification and mutilation}}
Female genital mutilation, also known as female circumcision or female genital cutting, is genital modification with no health benefits.<ref name="Crooks"/><ref name="WHO, FGM">{{cite web |title=Female genital mutilation |website=Media centre |publisher=[[World Health Organization]] |access-date=August 22, 2012 |url=https://www.who.int/mediacentre/factsheets/fs241/en/index.html |archive-date=July 2, 2011 |archive-url=https://web.archive.org/web/20110702174226/http://www.who.int/mediacentre/factsheets/fs241/en/index.html |url-status=live }}</ref> 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.<ref name="WHO, FGM"/>
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.<ref name="WHO, FGM"/><ref name="Momoh"/> In these societies, a girl is often not considered an adult unless she has undergone the procedure.<ref name="WHO, FGM"/>
==Other animals==
[[File:Cambridge Natural History Mammalia Fig 047.png|thumb|1902 illustration of the female reproductive system of a [[European rabbit]] (vagina labeled "va")]]
The vagina is a structure of animals in which the female is [[internal fertilization|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 [[theria|therian mammals]] ([[Placentalia|placentals]] and [[marsupial]]s), 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#Other animals|urogenital sinus]] or exit through the external vestibule.<ref name=VB/><ref>{{cite book|last=Linzey|first=Donald W.|title=Vertebrate Biology: Systematics, Taxonomy, Natural History, and Conservation|publisher=Johns Hopkins University Press|year=2020|page=306|isbn=978-1-42143-733-0|url=https://books.google.com/books?id=Rur4DwAAQBAJ&pg=PA306|access-date=3 December 2024|archive-date=22 January 2024|archive-url=https://web.archive.org/web/20240122190826/https://books.google.com/books?id=Rur4DwAAQBAJ&pg=PA306|url-status=live}}</ref> Female marsupials [[Marsupial#Female reproductive system|have two lateral vaginas]], which lead to separate uteri, but both open externally through the same orifice;<ref>{{Cite book |last=Tyndale-Biscoe |first=C. Hugh |url=https://books.google.com/books?id=KqtlPZJ9y8EC&q=vagina |title=Life of Marsupials |date=2005 |publisher=Csiro Publishing |isbn=978-0-643-06257-3 |language=en}}</ref> a third canal, which is known as the median vagina, and can be transitory or permanent, is used for birth.<ref name="Tyndale-BiscoeRenfree1987">{{cite book|author1=Hugh Tyndale-Biscoe|author2=Marilyn Renfree|title=Reproductive Physiology of Marsupials|url=https://books.google.com/books?id=HpjovN0vXW4C|date=January 30, 1987|publisher=Cambridge University Press|isbn=978-0-521-33792-2|access-date=August 18, 2018|archive-date=February 15, 2017|archive-url=https://web.archive.org/web/20170215191713/https://books.google.com/books?id=HpjovN0vXW4C|url-status=live}}</ref> The female [[spotted hyena]] does not have an external vaginal opening. Instead, the vagina [[Female genitalia of spotted hyenas|exits through the clitoris]], allowing the females to urinate, copulate and give birth through the clitoris.<ref name="courtship">{{cite journal |vauthors=Szykman M, Van Horn RC, Engh AL, Boydston EE, Holekamp KE |year=2007 |title=Courtship and mating in free-living spotted hyenas |url=http://tuvalu.santafe.edu/~bowles/Dominance/Papers/SzykmanetalHyenaMatingBehaviour2007.pdf |journal=Behaviour |volume=144 |issue=7 |pages=815–846 |doi=10.1163/156853907781476418 |bibcode=2007Behav.144..815S |citeseerx=10.1.1.630.5755 |access-date=April 24, 2014 |archive-date=November 30, 2012 |archive-url=https://web.archive.org/web/20121130193631/http://tuvalu.santafe.edu/~bowles/Dominance/Papers/SzykmanetalHyenaMatingBehaviour2007.pdf |url-status=dead }}</ref> The vagina of the female [[coyote]] contracts during copulation, forming a [[Canine reproduction#Copulation|copulatory tie]].<ref name = "Bekoff">{{Cite journal |vauthors=Bekoff M, Diamond J |title=Precopulatory and Copulatory Behavior in Coyotes |journal=[[Journal of Mammalogy]] |volume=57 |issue=2 |pages=372–375 |date=May 1976 |jstor=1379696 |doi=10.2307/1379696}}</ref>
[[Monotreme]]s, [[bird]]s, [[reptile]]s and [[amphibian]]s 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.<ref name="Iannaccone">{{cite book|vauthors=Iannaccone P|title=Biological Aspects of Disease|publisher=[[CRC Press]]|isbn=978-3-7186-0613-9|year=1997|pages=315–316|url=https://books.google.com/books?id=CNt2tOsBnc8C&pg=PA315|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506182528/https://books.google.com/books?id=CNt2tOsBnc8C&pg=PA315|url-status=live}}</ref><ref name="Fishbeck">{{cite book|vauthors=Fishbeck DW, Sebastiani A|title=Comparative Anatomy: Manual of Vertebrate Dissection|publisher=Morton Publishing Company|isbn=978-1-61731-004-1|year=2012|pages=66–68|url=https://books.google.com/books?id=JijAAgAAQBAJ&pg=PA66|access-date=October 27, 2015|archive-date=April 24, 2016|archive-url=https://web.archive.org/web/20160424114909/https://books.google.com/books?id=JijAAgAAQBAJ&pg=PA66|url-status=live}}</ref> 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.<ref name="Fishbeck" /> 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 [[invertebrate]]s, the vagina can be a part of the oviduct (see [[insect reproductive system]]).<ref name="Chapman">{{cite book|vauthors=Chapman RF, Simpson SJ, Douglas AE|title=The Insects: Structure and Function|publisher=[[Cambridge University Press]]|isbn=978-0-521-11389-2|year=2013|pages=314–316|url=https://books.google.com/books?id=NXJEi8fo7CkC&pg=PA314|access-date=October 27, 2015|archive-date=May 6, 2016|archive-url=https://web.archive.org/web/20160506231049/https://books.google.com/books?id=NXJEi8fo7CkC&pg=PA314|url-status=live}}</ref> Birds have a cloaca into which the urinary, reproductive tract (vagina) and gastrointestinal tract empty.<ref>{{Cite news|url=https://www.thespruce.com/glossary-definition-cloaca-385197|title=What Is a Bird's Cloaca?|work=The Spruce|access-date=January 13, 2018|archive-date=January 13, 2018|archive-url=https://web.archive.org/web/20180113203138/https://www.thespruce.com/glossary-definition-cloaca-385197|url-status=live}}</ref> Females of some waterfowl species have developed vaginal structures called dead end sacs and clockwise coils to protect themselves from [[Sexual coercion among animals|sexual coercion]].<ref name="twenty six">Brennan, P. L. R., Clark, C. J. & Prum, R. O. Explosive eversion and functional morphology of the duck penis supports sexual conflict in waterfowl genitalia. Proceedings: Biological Sciences 277, 1309–14 (2010).</ref>
A lack of research on the vagina and other female genitalia, especially for different animals, has stifled knowledge on female sexual anatomy.<ref name="Yong E">{{cite web|vauthors=Yong E|title=Where's All The Animal Vagina Research?|publisher=[[National Geographic Society]]|date=May 6, 2014|access-date=June 6, 2018|url=https://www.nationalgeographic.com/science/phenomena/2014/05/06/wheres-all-the-animal-vagina-research/|archive-date=July 7, 2018|archive-url=https://web.archive.org/web/20180707172541/https://www.nationalgeographic.com/science/phenomena/2014/05/06/wheres-all-the-animal-vagina-research/|url-status=dead}}</ref><ref>{{cite web|vauthors=Cooper D|title=Female genitalia shunned by researchers|publisher=[[ABC Online]]|date=May 7, 2014|access-date=June 6, 2018|url=http://www.abc.net.au/science/articles/2014/05/07/3999220.htm|archive-date=January 11, 2019|archive-url=https://web.archive.org/web/20190111010513/http://www.abc.net.au/science/articles/2014/05/07/3999220.htm|url-status=live}}</ref> 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.<ref name="Yong E"/> 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]].<ref name="Yong E"/>
Non-human [[primate]]s are optimal models for human biomedical research because humans and non-human primates share physiological characteristics as a result of [[evolution]].<ref name="Sarmento">{{cite book|vauthors=Sarmento B|title=Vitro Culture Models|publisher=[[Woodhead Publishing]]|isbn=978-0-08-100114-1|year=2015|page=296|url=https://books.google.com/books?id=GdmoBAAAQBAJ&pg=PA296|access-date=January 14, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703221609/https://books.google.com/books?id=GdmoBAAAQBAJ&pg=PA296|url-status=live}}</ref> While menstruation is heavily associated with human females, and they have the most pronounced menstruation, it is also typical of [[ape]] relatives and [[monkey]]s.<ref name="Burton">{{cite book|vauthors=Burton FD|title=The Multimedia Guide to the Non-human Primates: Print Version|publisher=Prentice Hall Canada|isbn=978-0-13-209727-7|year=1995|page=290|url=https://books.google.com/books?id=hqNFAQAAIAAJ|access-date=June 5, 2018|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310000719/https://books.google.com/books?id=hqNFAQAAIAAJ|url-status=live}}</ref><ref name="Martin">{{cite book|vauthors=Martin R|title=How We Do It: The Evolution and Future of Human Reproduction|publisher=[[Basic Books]]|isbn=978-0-465-03015-6|year=2013|page=27|url=https://books.google.com/books?id=Up8WBQAAQBAJ&pg=PA27|access-date=June 5, 2018|archive-date=July 3, 2019|archive-url=https://web.archive.org/web/20190703211400/https://books.google.com/books?id=Up8WBQAAQBAJ&pg=PA27|url-status=live}}</ref> Female [[macaques]] menstruate, with a cycle length over the course of a lifetime that is comparable to that of female humans. Estrogens and [[progestogen]]s in the [[Menstruation (mammal)|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]].<ref name="Sarmento"/> 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.<ref name="Sarmento"/> This is one reason why, although macaques are used for studying HIV transmission and testing [[microbicides]],<ref name="Sarmento"/> 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.<ref name="Kumar">{{cite book|vauthors=Kumar B, Gupta S|title=Sexually Transmitted Infections - E-book|publisher=[[Elsevier Health Sciences]]|isbn=978-81-312-2978-1|year=2014|page=1286|url=https://books.google.com/books?id=kQ9tAwAAQBAJ&pg=PA1286|access-date=January 14, 2018|archive-date=July 4, 2019|archive-url=https://web.archive.org/web/20190704044853/https://books.google.com/books?id=kQ9tAwAAQBAJ&pg=PA1286|url-status=live}}</ref>
== See also ==
{{Portal|Human sexuality|Anatomy}}
* [[Artificial vagina]]
* [[Stigma (botany)]]
* [[Supravaginal portion of cervix]]
* [[Uterine inversion]]
* [[Vaginal dilator]]
* [[Vaginal photoplethysmograph]]
==References==
{{Reflist|30em}}
==External links==
* [http://www.anatomyatlases.org/AnatomicVariants/OrganSystem/Text/Vagina.shtml ''Vagina''], Anatomical Atlases, an Anatomical Digital Library (2018)
* {{commons category-inline|Vaginas}}
* {{wiktionary-inline|vagina}}
{{Women's health|state=collapsed}}
{{Sex}}
{{Female reproductive system}}
{{Female genital procedures}}
{{Development of the reproductive system}}
{{Authority control}}
[[Category:Vagina| ]]
[[Category:Human female reproductive system]]
[[Category:Mammal female reproductive system]]
[[Category:Women and sexuality]]
[[Category:Women's health]]
[[Category:Anatomy]]
[[Category:Gynaecology]]
[[Category:Sex organs]]