Postmenopausal Vulvar Disorders
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The postmenopausal vulva is characterized by a decline in skin barrier function associated with aging and estrogen deficiency that contributes to increased susceptibility to a variety of 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 biopsy when necessary. Therapy is targeted at the underlying etiology.
White lesions are seen with lichen sclerosus, 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 a squamous cell carcinoma in affected skin may be as high at 5%. Raised lesions, persistent ulceration, or lack of response to treatment should prompt a biopsy. Lichen planus is less common and may also involve the vagina, oral mucosa, skin, and nails. It presents in a variety of forms, including thickened white plaques, violaceous papules, and erythematous erosions. 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 with hormone therapy and vulvar care with gentle cleansers and avoidance of irritants. Lichen simplex chronicus is often triggered by underlying conditions such as atopic dermatitis, psoriasis and seborrheic dermatitis. It is characterized by lichenification and excoriations caused by the itch-scratch cycle. Treatment involves 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 is often seen in patients with diabetes or immune suppression. Diagnosis is made based on well-demarcated red plaques, possibly associated with classic vaginal discharge and excoriations. Treatment is with antifungals. Psoriasis is also characterized by red plaques with well-defined borders, and diagnosis is aided by a personal or family history. 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. Elimination of irritants, emollients, and possible steroid therapy are the mainstays of therapy.
Dysplasia and malignancy must be considered in patients with vulvar lesions. A history of HPV-related illness should raise suspicion, and any bleeding, nodule, or non-healing ulcer should be biopsied. Paget’s disease presents with red plaques with raised edges and white islands of tissue. Biopsy should be directed at any suspicious lesions or whenever 6 weeks of treatment for benign vulvar disease fails to resolve symptoms.
Any lesion without a classic presentation or that does not respond to treatment should undergo biopsy.
Kingston A., Vulval disease in the postmenopausal patient: a guide to current management. Menopause Int. 2010 Sep;16(3):117-20. doi: 10.1258/mi.2010.010031.
Olsson A, Selva-Nayagam P, Oehler MK., Postmenopausal vulval disease. Menopause Int. 2008 Dec;14(4):169-72. doi: 10.1258/mi.2008.008030.
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
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