Editing Vagina (section)

===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" />