Pigmented lesions arising in the lower female genital tract most commonly are found on the vulva and rarely in the vagina. Peri-genital and genital pigmented lesions are identified in up to 10–12% of women in a primary care setting. Pigmented lesions do not always correspond to a melanocytic neoplasm; inflammatory processes, squamous lesions, and vascular lesions may all mimic melanocytic proliferations. This chapter seeks to provide an overview of the salient clinical and histologic features of various pigmented melanocytic lesions of the vulva. Melanocytes normally reside in the basal layer of the epidermis of vulvar skin and mucosa, and the normal density of melanocytes in the peri-genital region is higher than in other cutaneous sun-protected sites. While the majority of pigmented lesions encountered in the lower genital tract are benign, the clinical appearance can be worrisome and the presence of such lesions may be concerning to patients. The most common benign lesions include lentigines (melanotic macules), vulvar melanosis, and common acquired nevi. Melanocytic nevi arising in the peri-genital region may sometimes show architectural and cytologic irregularities that may be a frequent source of consternation for pathologists. These atypical nevi—encompassing atypical melanocytic nevus of the genital type, nevi arising in the setting of lichen sclerosus, and dysplastic nevi—may mimic melanoma clinically and histologically. Much less frequently, the presence of a pigmented lesion on the vulva reflects malignant melanoma. Vulvar melanoma, although rare, is the second most common malignancy of the vulva after squamous cell carcinoma. Overall, vulvar melanoma generally presents at an advanced stage and therefore has a poor prognosis. Prognostic features of importance and molecular signatures of vulvar melanoma will also be discussed. In general, familiarity with clinical features of malignancy and having a low threshold for biopsy of suspicious lesions are important for clinicians to increase the chances of early detection, which will significantly improve prognosis. Likewise, it is important for pathologists to recognize common and uncommon melanocytic lesions and to distinguish melanoma from its mimickers. This chapter seeks to address these issues and give pathologists a framework with which to handle these challenging specimens.