Common Vulvar Diseases in Postmenopausal Women
Genitourinary Syndrome of Menopause (Vulvovaginal Atrophy)
Genitourinary syndrome of menopause is the most prevalent vulvar condition in postmenopausal women, affecting approximately 50% of this population and resulting from hypoestrogenic states that cause thinning, drying, and inflammation of vulvovaginal tissues. 1, 2, 3
Clinical Presentation
- Vaginal dryness, itching, and burning sensation are the hallmark symptoms 1, 2
- Dyspareunia (painful intercourse) occurs frequently and significantly impacts quality of life 1, 4
- Urinary symptoms including urgency and recurrent urinary tract infections may develop 1, 2
- Unlike vasomotor symptoms that resolve over time, vulvovaginal atrophy symptoms persist indefinitely and typically worsen without treatment 1
Treatment Algorithm
Start with non-hormonal interventions: apply vaginal moisturizers 3-5 times weekly (not the standard 2-3 times) to the vagina, vaginal opening, and external vulva, combined with water-based or silicone-based lubricants during sexual activity. 1
- Silicone-based products provide longer-lasting relief than water-based or glycerin-based alternatives 1, 5
- If symptoms persist after 4-6 weeks of consistent use, escalate to low-dose vaginal estrogen therapy 1
- Low-dose vaginal estrogen (tablets, creams, or sustained-release rings) is the most effective treatment, with minimal systemic absorption and no increased risk of endometrial hyperplasia 1, 6
- For women who have undergone hysterectomy, estrogen-only vaginal therapy offers the most favorable risk-benefit profile 1
Alternative Prescription Options
- Vaginal DHEA (prasterone) is FDA-approved for postmenopausal dyspareunia and improves sexual desire, arousal, pain, and overall function 1, 5
- Ospemifene (oral SERM) effectively treats moderate-to-severe dyspareunia and vaginal dryness in postmenopausal women without breast cancer history 1, 7
- Pelvic floor physical therapy improves sexual pain, arousal, lubrication, and satisfaction 1, 5
Lichen Sclerosus
Lichen sclerosus is a chronic inflammatory condition characterized by porcelain-white papules and plaques with intense vulvar itching, occurring most commonly in postmenopausal women and carrying a 4-5% risk of progression to vulvar squamous cell carcinoma. 8
Clinical Features
- Porcelain-white papules and plaques with areas of ecchymosis and follicular delling 8
- Lesions occur in the interlabial sulci, labia minora, clitoral hood, clitoris, and perineal body 8
- Perianal involvement occurs in 30% of female cases 8
- Intense itching worse at night, potentially disturbing sleep 8
- Pain occurs with erosions or fissures; dyspareunia develops with introital narrowing 8
- Vaginal and cervical mucosa are always spared, distinguishing it from lichen planus 8
Pathogenesis and Risk Factors
- Autoimmune mechanisms are strongly implicated: 22% of patients have autoimmune disease, 42% have autoantibodies, and associations exist with thyroid disease (6%), vitiligo (6%), and alopecia areata (9%) 8
- The highest incidence occurs in low-estrogen states (prepubertal girls and postmenopausal women), though no association exists with pregnancy, hysterectomy, or hormone replacement 8
- Local trauma (Koebner phenomenon) may trigger disease onset 8
Malignancy Risk
Women with lichen sclerosus have a 4-7% lifetime risk of developing vulvar squamous cell carcinoma, with lichen sclerosus found in adjacent areas in more than 60% of vulvar SCC cases. 8
- Cellular immune dysregulation may create a permissive environment for malignant transformation 8
- Extragenital lichen sclerosus does not carry malignancy risk 8
- Close monitoring for malignant changes is essential 8
Treatment
- Ultrapotent topical corticosteroids are first-line therapy 8, 2
- Topical calcineurin inhibitors may be used in select cases 2
- "Complicated" lichen sclerosus with squamous cell hyperplasia often responds poorly to corticosteroids 8
Lichen Planus
Lichen planus is an inflammatory autoimmune disorder affecting the vulva and vagina in addition to other skin and mucosal surfaces, with significant scarring potential if left untreated. 2
Clinical Characteristics
- Unlike lichen sclerosus, lichen planus can involve vaginal and cervical mucosa 8
- Erosive lesions and scarring are common complications 2
- May cause introital narrowing and vaginal stenosis 2
Treatment
- Topical corticosteroids are first-line therapy 2
- Early treatment is critical to prevent irreversible scarring 2
Lichen Simplex Chronicus
Lichen simplex chronicus manifests as persistent itching and scratching of vulvar skin leading to thickened epithelium, with treatment focused on breaking the itch-scratch cycle. 2
Clinical Features
- Chronic scratching leads to lichenification (thickened, leathery skin) 2
- The condition perpetuates itself through the itch-scratch cycle 2
Treatment
- Topical corticosteroids to break the itch-scratch cycle 2
- Behavioral interventions to reduce scratching 2
Vulvodynia
Vulvodynia is a common vulvar pain disorder diagnosed by exclusion, requiring a multimodal treatment approach including vulvar hygiene, physical therapy, psychosocial interventions, and antineuropathy medications. 2
Management Strategy
- Vulvar hygiene modifications 2
- Pelvic floor physical therapy 2
- Psychosocial interventions 2
- Antineuropathy medications (gabapentin, tricyclic antidepressants) 2
- Topical lidocaine for localized vestibular pain 1
Special Considerations for Cancer Survivors
Breast Cancer Patients
For women with hormone-positive breast cancer, non-hormonal options (moisturizers and lubricants) must be tried first for at least 4-6 weeks before considering low-dose vaginal estrogen, which requires thorough discussion of risks and benefits with the patient's oncologist. 1, 9
- A large cohort study of nearly 50,000 breast cancer patients followed for 20 years showed no increased breast cancer-specific mortality with vaginal estrogen use 1
- Estriol-containing preparations may be preferable for women on aromatase inhibitors, as estriol cannot be converted to estradiol 1, 9
- Vaginal DHEA is specifically recommended for aromatase inhibitor users who haven't responded to non-hormonal treatments 1, 9
Post-Radiation Patients
- Radiation therapy causes long-term complications including fibrosis, stenosis, and vulvovaginal atrophy 9
- Vaginal dilators and moisturizers should be used routinely post-radiation to prevent stenosis 9
Critical Pitfalls to Avoid
- Insufficient moisturizer frequency: Apply 3-5 times weekly, not the standard 2-3 times 1
- Internal-only application: Moisturizers must be applied to the vaginal opening and external vulva, not just internally 1
- Delaying treatment escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen 1
- Missing malignancy surveillance: Women with lichen sclerosus require close monitoring for vulvar squamous cell carcinoma 8
- Confusing systemic HRT contraindications with vaginal estrogen: The USPSTF recommendation against systemic hormone therapy does not apply to low-dose vaginal estrogen for symptomatic vulvovaginal atrophy 1