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Postmenopausal Vulvar Disorders

Author: Elizabeth A. Ferries-Rowe, MD

Editor: Sireesha Reddy, MD

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A decline in skin barrier function associated with aging and estrogen deficiency contributes to an increased susceptibility to various postmenopausal vulvar conditions. The most common symptoms are itching and burning. Women often delay care and present with a long history of ineffective treatment for presumed vulvovaginal candidiasis. Diagnosis involves recognizing the typical appearance of common conditions and performing a biopsy when necessary. Therapy involves targeting the underlying etiology.

White lesions occur in lichen sclerosis, lichen planus, atrophic vulvitis, and lichen simplex chronicus. Lichen sclerosus is the most common and typically presents with ‘figure-of-eight’ plaques around the vulva, perineum, and anus with a ‘cigarette paper’ appearance. Treatment with topical clobetasol is effective. Diagnosis is clinical, and the risk of developing squamous cell carcinoma in affected skin may be as high as 5%. Raised lesions, persistent ulceration, or lack of response to treatment should prompt a biopsy. Lichen planus is less common and may involve the vagina, oral mucosa, skin, and nails. It presents in various forms, including thickened white plaques, violaceous papules, and erythematous erosions. The first-line therapy is topical steroids.

Atrophic vulvitis presents with pallor, loss of rugation, petechiae, and loss of pubic hair and adipose tissues. Primary treatment is hormone therapy and vulvar care with gentle cleansers and avoiding irritants. Triggers for lichen simplex chronicus are underlying conditions such as atopic dermatitis, psoriasis, and seborrheic dermatitis. The diagnostic criteria of lichenification and excoriations result from itch-scratch cycles. Treatment involves the elimination of irritants, mild topical steroids, and sedating antihistamines at night.

Red lesions may represent candidal vulvovaginitis, psoriasis, contact dermatitis, or lichen planus. Candidal vulvovaginitis often inflicts patients with diabetes or immune suppression. Hallmarks of diagnosis are well-demarcated red plaques, possibly associated with classic vaginal discharge and excoriations. Treatment is with antifungals. Psoriasis characteristics are red plaques with well-defined borders, and a personal or family history aids the diagnosis. Treatment is with topical steroids, weak tar preparations, and calcipotriol ointment. Contact dermatitis presents with erythema and possible edema, excoriations, and erosions. Patients often have a history of over-washing and exposure to irritants, including urine and feces. Eliminating irritants and using emollients and steroid therapy are the mainstays of therapy.

Paget’s disease presents with red plaques with raised edges and white islands of tissue. Evaluation for dysplasia and malignancy in patients with vulvar lesions is necessary. A history of HPV-related diagnosis, bleeding lesion, palpated nodule, a non-healing ulcer, and any failed treatment for benign vulvar disease raises the suspicion of malignancy to consider a biopsy.

Any lesion without a classic presentation that does not respond to treatment should undergo biopsy.

Further Reading:

van der Meijden WI, Boffa MJ, Ter Harmsel WA, Kirtschig G, et. al. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol. 2017 Jun;31(6):925-941. doi: 10.1111/jdv.14096. Epub 2017 Feb 6. PMID: 28164373.

Stockdale CK, Boardman L. Diagnosis and Treatment of Vulvar Dermatoses. Obstet Gynecol. 2018 Feb;131(2):371-386. doi: 10.1097/AOG.0000000000002460. PMID: 29324620.

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. Diagnosis and Management of Vulvar Skin Disorders: ACOG Practice Bulletin, Number 224. Obstet Gynecol. 2020 Jul;136(1):e1-e14. doi: 10.1097/AOG.0000000000003944. PMID: 32590724.

Initial Approval: April 2009, Revised September 2018. Reaffirmed March 2020; Minor Revision November 2021. Minor Revision September 2023.


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