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The postmenopausal vulva

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The postmenopausal vulva

Post by mandible on Fri Mar 05, 2010 3:00 am

Introduction
The postmenopausal vulva shows remarkable
resistance to external irritation, in contrast to aged
skin elsewhere on the body.1 There are, however,
several changes in ageing vulval skin that do
predispose to mechanical and chemical injury over
time. The vulva is close to the rectum, which
harbours bacterial pathogens, and the relative
hydration of the vulva increases its overall
susceptibility to injury. Furthermore,with the
menopause comes compromise in barrier function.
This is due in part to estrogen deficiency and in part
to ageing, both of which cause a rise in skin pH
from its usual acidity, resulting in a decrease in the
antimicrobial defences of the skin.1,2 There is also a
loss of lipid production,which slows healing in
response to injury1 and perhaps explains why
restoration of lipids by topical application, for
example of linoleic acid, is so useful in vulval care.
Finally, cell-mediated immunity is less efficient in
ageing skin and this also is considered to increase
the risk of infection.1
In spite of being less permeable to irritants than
other aged skin, vulval skin is particularly
vulnerable to excessive cleansing and abrasion from
clothing or panty liners and ammonia,1 which is
often present where there is urinary incontinence.
Cream bases,which contain propylene glycol,
parabens and fragrances, can often cause irritation
and, therefore, ointments are preferable.
Box 1 shows the conditions that affect the
postmenopausal vulva. The vulval history should
be tailored to reach a differential diagnosis; this is a
mixture of questions instinctive to a gynaecologist
and familiar to a dermatologist.An example is
provided for reference in Box 2.
Atrophic vulvovaginitis
The menopause is big business in the medical and
pharmaceutical worlds and it is easy to see why.
Whereas vasomotor symptoms of the menopause
will be alleviated in time in the majority of cases,
vulval symptoms progress with age. The Women’s
Health Initiative data2 revealed that vulvovaginal
symptoms, including dryness, irritation and itching,
affect up to 27% of postmenopausal women and
other studies have supported this observation.
Vulval atrophy is common after the menopause and
often presents with nonspecific symptoms of
dryness, dyspareunia, soreness and irritation.
Urogenital symptoms and postmenopausal
bleeding can also be associated with atrophy caused
by estrogen deficiency, as the vaginal walls become
thinner with loss of collagen and increased
friability.
Dyspareunia may be experienced by as many as
40% of sexually active menopausal women but, as
only a third of women seek help for vulvovaginal
symptoms of any kind,2 those who do make it in to
our clinics deserve specific enquiry as to the
presence of any sexual dysfunction.
Examination of the atrophic vulva reveals pallor,
loss of rugation, petechiae and loss of pubic hair.
Loss of adipose tissue is common and among some
women there may be labial fusion, introital
narrowing or even stenosis. It is essential to exclude
other diagnoses such as those mentioned below.
Treatment of vulval symptoms should always begin
with general vulval care. The removal of causes of
irritation to the vulval skin is of paramount
importance and is the aspect of treatment most
likely to be forgotten by the gynaecologist and
ignored by the woman (Box 3).
The British Menopause Society’s summary practice
points3 regarding hormone replacement therapy
(HRT) include the following:
• In the UK most women who request HRT do so
for symptom relief, often using it for a short time
(less than 5 years), and it is the most effective
treatment.
• Given appropriately, the benefits of HRT
outweigh any risks and its use should not be
restricted.
The North American Menopause Society has
specific recommendations2 regarding vulvovaginal
symptoms, including the following:
• [Primary goals] are symptom relief and reversal
of atrophic anatomical changes.
• When low-dose estrogen is administered locally
for vaginal atrophy, progestogen is generally not
indicated.
• Prescription vaginal estrogen delivery is effective
and well tolerated in treating vaginal atrophy.
• Vaginal estrogen therapy should be continued for
as long as women have distressing symptoms.
Systemic HRT is indicated only for the treatment of
vasomotor symptoms.
Lichen sclerosus
(See Figure 1 and Figure 2.) A common dermatosis
affecting mainly the vulval, perineal and perianal
skin of the postmenopausal woman, lichen
Box 1
Vulval conditions associated with
the menopause
Common Less common Rare
Atrophic vulvitis Squamous cell Lichen planus
carcinoma
Lichen sclerosus Paget disease
Irritant dermatitis Vulvodynia
Lichen simplex
chronicus
sclerosus manifests often as a chronic relapsing
disease which is managed symptomatically. Lichen
sclerosus has a predilection for genital skin and can
be found among adults of both genders and
prepubertal girls. Extragenital lesions are found in
approximately 11% of cases (Figure 3). The
terminology used for lichen sclerosus has been
standardised by the International Society for the
Study of Vulvovaginal Disease (ISSVD) and the
expression ‘lichen sclerosus et atrophicus’ is no
longer used, as not all lichen sclerosus is atrophic.
‘Leucoplakia’ and ‘kraurosis vulvae’ are out-of-date
terms. The evidence base surrounding
management of lichen sclerosus is poor and
established guidance is based on best practice.5
Aetiology remains unknown, several authors
suggesting autoimmune involvement, and there is
certainly association with other autoimmune
diseases. Presentation is usually with intense vulval
itching, but soreness or burning may be the
primary symptom, particularly where there has
been chronic itch. Pruritis is often worse at night
and many women have disturbed sleep.
Asymptomatic lichen sclerosus is also seen;
treatment in these instances is probably only
needed if there is evidence of active disease.
Clinical diagnosis of lichen sclerosus is accepted as
standard practice,with histology reserved for
diagnostically difficult cases, those which fail to
respond to treatment and suspicious areas.5
Outpatient biopsy under local anaesthesia is well
tolerated and in some UK clinics is routinely used
for diagnosis. The classic appearance of lichen
sclerosus is of porcelain-white plaques on the vulva,
perineum and perianal skin. The texture of
‘parchment’or ‘cigarette paper’ is characteristic and
helps to distinguish lichen sclerosus from lichen
planus or vitiligo.Areas involved include the labia
minora and majora, vestibule, clitoral hood and
perineum. Distribution is often described as a
‘figure-of-eight’ around the perianal skin. Other
features include fissuring and erosions which
frequently produce soreness and pain, ecchymoses
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Box 2
History of presenting symptom Itch, night-time scratching Example of vulval history
Pain: provoked, unprovoked
Duration of symptoms
Onset
Exacerbating/relieving factors
Vulval hygiene Bath/shower
Skin cleansing agents
Moisturisers
Baby wipes
Panty liners
Urinary incontinence
Past medical history Skin disease
Atopic disease
Autoimmune disease
Gynaecological history Smears, past and present
Hysterectomy, oophorectomy
Date of menopause and its effects
Sexual history
Obstetric history
Drug history Topical treatments tried and their effects (self-administered or prescribed)
Other medication and periods of use (including HRT)
Social history Impact of vulval symptoms on quality of life
Occupations
Family members
Box 3
Do not Do Vulval care
use soap, shower gel or detergent to cleanse use a soap substitute, such as cetomacrogol, aqueous cream or Epaderm®️a
shampoo hair in the bath or shower shampoo over a basin
use bubble bath, oils or disinfectants in the bath use substitutes such as Oilatum®️b or Balneum®️c in the bath
wear tight or synthetic material trousers or briefs wear cotton knickers, skirts, loose garments
wear panty liners avoid panty liners and address incontinence
wash excessively use plenty of emollients
use wet wipes, feminine wipes, etc.
aSoft paraffin; Medlock Medical, Oldham, UK
bLiquid paraffin; Stiefel, High Wycombe, UK
cUrea 5%; Crookes, Hull, UK
and hyperkeratosis, which appears as thickened
white areas. The vaginal vault and cervix are spared
in lichen sclerosus; in lichen planus there is vaginal
involvement in up to 70% of cases.6 In the presence
of fissuring and bruising, clinicians should consider
a differential diagnosis of sexual abuse, particularly
among vulnerable adults.Vulval Paget disease is a
rare differential diagnosis which requires more
specialist input in view of the high risk of associated
malignancy.
The lifetime risk of squamous cell carcinoma in
cases of lichen sclerosus is low and estimates of less
than 5% are likely to be higher than actual risk
owing to the probable high prevalence of
undiagnosed lichen sclerosus.5,7 In the anogenital
area approximately 60% of squamous cell
carcinoma presents on a background of lichen
sclerosus; however, this is not true elsewhere in the
body.
The guidelines used by the British Association of
Dermatologists suggest that all women with
symptomatic or active lichen sclerosus should
ideally be seen at least once by a dermatologist
and that women with difficult cases should be seen
in a multidisciplinary vulval clinic.5 Certainly,
management is sometimes problematic and should
involve clinicians with a special interest in the field;
there are many such multidisciplinary clinics
within the UK.
Recommended treatment for lichen sclerosus
includes the administration of clobetasol
propionate (e.g.Dermovate®️, GSK,Uxbridge,
UK)4–7 which is an ultrapotent topical steroid;
ointment should be used in preference to cream, as
outlined previously. In one of the regimens
suggested, the ointment is applied once or twice
daily for a month, reducing to once daily or
alternate days for the next month and to twice
weekly for the third month.5,8 Recent evidence does
indicate that there is no advantage in applying
topical steroids more than once daily.Vulval care,
as described above, is also recommended.
Follow-up of women with lichen sclerosus remains
contentious. Follow-up to ensure initial response to
and compliance with the treatment initiated seems
logical, but long-term follow-up to monitor for
malignant change is likely to be beyond the
capacity of the NHS. Risk is low but change likely
to be rapid, which would necessitate very regular
examination.As a minimum,women should be
advised to report non-healing ulcers, bleeding, any
lumps and any uncontrolled symptoms.Women
with disease that is difficult to manage should
remain under the care of a specialist.
Topical steroid use
Concerns regarding treatment involving steroids
are well known to the public and clinicians
inexperienced in the administration of ultrapotent
topical steroids may share some of these fears. Such
anxieties often result in lack of compliance with
treatment, which can be confused for steroid
resistance.Women do require consistency in the
advice they receive from all the clinicians with
whom they come into contact. The pharmaceutical
companies do little to help, as the packet insert for
their steroid will frequently warn against use of
their product in the anogenital area. Steroids can
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©️ 2009 Royal College of Obstetricians and Gynaecologists
Figure 1
Vulval lichen sclerosus. Image
courtesy of Dr R Meyrick-Thomas,
Consultant Dermatologist, Salisbury
District Hospital, Salisbury, UK
Figure 2
Vulval lichen sclerosus. Image
courtesy of Dr R Meyrick-Thomas
cause unsightly atrophy of the skin, but vulval skin
is more resistant to this effect.Although specific
evidence is lacking, systemic absorption leading to
adrenal suppression from vulval steroid treatment
is virtually unheard of and many clinics have safely
used vulval steroids for decades.
Contact dermatitis
Inflammation of the skin resulting from irritation
by an external agent (irritant dermatitis) or
allergen (allergic dermatitis) is a very common
cause of vulval symptoms. Itching, burning and
irritation are all nonspecific symptoms and they
can present suddenly or gradually.Contact
dermatitis may be a secondary condition and other
diagnoses underlying the symptoms should be
considered.
Allergic dermatitis is seen less often after the
menopause. The history should provide the
diagnosis: reaction may be sudden and severe,
resulting in vesiculation, erosion and weeping of
the skin,with oedema and crusting.Common
allergens are nail polish,Vagisil®️(Combe
International Ltd,Croydon, UK), latex,
preservatives and lanolin and, rarely but
interestingly, semen has been shown to cause
contact dermatitis on occasion. Patch testing can
help to identify allergens among women with
ongoing symptoms.
Irritant dermatitis in the vulval area is common: as
mentioned above, estrogen deficiency reduces the
resistance of the vulval skin to irritants.Common
irritants include panty liners, detergents and
lubricants; a history of excessive vulval washing
should be sought.Urinary incontinence is a
frequent cause of irritation and can easily be
addressed by a gynaecologist. Examination will
reveal erythema which is often localised to the area
of contact unless the offending product is a liquid,
but this sign may be only mild and therefore
missed.More severe reactions can lead to oedema,
scaling and even erosions. Pruritis can lead to
superimposed lichen simplex chronicus, described
below.
Treatment begins with identification of the allergen
or irritant and removal of all possible offending
agents. The use of a soap substitute and emollients
can cause burning or stinging initially in severe
cases. Low- or midpotency topical steroids may be
used for 7–10 days to treat inflammation4,7 and, in
severe cases, oral steroids may be considered.Do
not forget to look for superimposed infection
requiring antibiotics or antifungals.
Lichen simplex chronicus
(See Figure 4.) Lichen simplex chronicus is a
secondary condition resulting from the itchscratch-
itch cycle. Often triggered by an underlying
vulval dermatosis or other pathology, lichen simplex
chronicus is characterised by intractable itching and
scratching, particularly during sleep.Examination
reveals lichenification with exaggerated skin
markings and excoriations. The cycle must be
broken and treatment requires an understanding by
the woman together with vulval care measures,
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©️ 2009 Royal College of Obstetricians and Gynaecologists
Figure 3
Cutaneous lichen sclerosus. Image
courtesy of Dr R Meyrick-Thomas
Figure 4
Lichen simplex chronicus. Image
courtesy of Dr R Meyrick-Thomas
sedating antihistamines (e.g. hydroxyzine) at night
and mild topical steroids to reduce inflammation.
Treatment of the triggering cause is required.
Lichen planus
This is a rare, probably autoimmune,
mucocutaneous disorder affecting 1% of all
women, most frequently in the mouth. Genital
lichen planus presents with intense itching, pain,
soreness, dyspareunia and bleeding.Where there is
vaginal involvement, a purulent discharge caused
by desquamative vaginitis is common.6
Vulval lichen planus has a heterogenous
presentation, the majority of cases manifesting as
erosive lichen planus (Figure 5) which affects the
mucous membranes and usually involves the
vestibule and vagina. On examination, the vulva
appears ‘red raw’with often nonspecific erosions.
Cutaneous lichen planus has a classic lesion,
which is well circumscribed, violaceous and flattopped,
found on the trunk and extremities;
nonmucous membrane genital lichen planus
generally conforms to this description.Wickham
striae may be seen on the buccal mucosa of the
mouth. These are pathognomonic and may be
found elsewhere; on the vulva they appear as
white reticular or linear papules.Advanced
disease of any subtype may present with
adhesions, synechiae, introital narrowing and
scarring.
Treatment can be difficult.As with all vulval
problems, irritants must be removed and
generalised vulval care measures instituted.
Potent or ultrapotent topical steroids constitute
first-line treatment and suppositories can be
used for vaginal disease. Daily application for up
to 3 months has been advocated,6 tapering as
required.Vaginal dilators should be used early in
vaginal involvement to prevent adhesions and
topical local anaesthetic gel can help with
discomfort. Surgery is reserved for reversal of
severe scarring, particularly for younger or
sexually active women.
Lichen planus is very often misdiagnosed as lichen
sclerosus because of similarities in presentation and
the presence of white plaques. The waxy ‘cigarette
paper’ textural change of lichen sclerosus is absent
in lichen planus, however, and vaginal involvement
precludes lichen sclerosus as a diagnosis. Lichen
sclerosus and lichen planus are thought to be
present simultaneously in some cases, perhaps
those with more resistant disease.5,6Histology is
diagnostic.
Vulvodynia
The ISSVD has recently defined vulvodynia as
‘vulval discomfort, most often described as
burning pain, occurring in the absence of
relevant visible findings or a specific, clinically
identifiable, neurologic disorder’, and has
subclassified it into provoked or unprovoked
and generalised or localised. All other
terminology, including vestibulitis, is now
obsolete. Diagnosis is made clinically by
exclusion of other causes. Pain mapping can be
performed by demonstrating tenderness to the
tip of a cotton swab.
These chronic pain sufferers have frequently seen
scores of physicians without reaching a diagnosis
and may have followed several treatment
regimens providing little or no relief. Treatment,
even in the face of now universally accepted
classification, is often difficult.Women should be
given written information and referred to selfhelp
groups for support. Treatment begins with
vulval care and local anaesthesia, which is
generally useful in provoked vulvodynia, and
moves on to systemic treatment. Therapies
known to be helpful in neuropathic pain may
work in some cases; agents include amitryptiline
and nortryptiline as first-line treatment;
gabapentin and pregbalin can be added.9–11
Cognitive behavioural therapy and biofeedback
to the pelvic floor have had limited success.9,10
Conclusion
The study of vulval disease is undertaken across
three specialties—genitourinary medicine,
dermatology and gynaecology. This gives rise to
the potential for significant variations in
diagnosis and treatment across specialties, which
258
Review 2009;11:253–259 The Obstetrician & Gynaecologist
©️ 2009 Royal College of Obstetricians and Gynaecologists
Figure 5
Erosive lichen planus. Image
courtesy of Dr R Meyrick-Thomas
has been a problem in past years.More recently,
however, the development of a multidisciplinary
specialty has allowed expertise from all three
fields to combine and offer a first-class service in
vulval care. A thorough vulval history and
focused examination will provide most of the
information needed for diagnosis. Clinicians
should not hesitate to refer women to vulval
specialists, ideally in multidisciplinary clinics.
Recommended websites
British Society for the Study ofVulval Disease
[[You must be registered and logged in to see this link.]
International Menopause Society
[[You must be registered and logged in to see this link.]
International Society for the Study of Vulvovaginal
Disease [[You must be registered and logged in to see this link.]
Vulval Pain Society [[You must be registered and logged in to see this link.]
Vulval Health Awareness Campaign [[You must be registered and logged in to see this link.]
References
1 Summers P, Hunn J. Unique dermatologic aspects of the
postmenopausal vulva. Clin Obstet Gynecol 2007;50:745–51.
doi:10.1097/GRF.0b013e3180db96ae
2 Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol
2008;51:549–55. doi:10.1097/GRF.0b013e3181809a26
3 The British Menopause Society. BMS consensus statements:
summary & practice points. Hormone replacement therapy
[[You must be registered and logged in to see this link.]
4 Farage MA, Miller KW, LedgerWJ. Determining the cause of
vulvovaginal symptoms. Obstet Gynecol Surv 2008;63:445–62.
doi:10.1097/OGX.0b013e318172ee25
5 Neill SM, Tatnall FM, Cox NH. Guidelines for the management
of lichen sclerosus. Br J Dermatol 2002;147:640–9.
doi:10.1046/j.1365-2133.2002.05012.x
6 Goldstein AT, Metz A. Vulvar lichen planus. Clin Obstet Gynecol
2005;48:818–23. doi:10.1097/01.grf.0000179670.98939.b7
7 Lynch PJ, Edwards L. Genital Dermatology. Philadelphia, PA: Churchill
Livingstone; 1994.
8 Lorenz B, Kaufman R, Kutzner S. Lichen sclerosus. Therapy with
clobetasol propionate. J Reprod Med 1998;43:790–4.
9 Haefner HK, Collins ME, Davis GD, Edwards L, Foster DC, Hartmann ED,
et al. The vulvodynia guideline. J Low Genit Tract Dis 2005;9:40–51.
doi:10.1097/00128360-200501000-00009
10 Reed BD. Vulvodynia, diagnosis and management. Am Fam
Physician 2006;73:1231–8.
11 Gunter J. Vulvodynia; new thoughts on a devastating
condition. Obstet Gynecol Surv 2007;62:812–7.
doi:10.1097/01.ogx.0000290350.14036.d6
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