Noninvasive vulvar lesions An illustrated guide to ... - Urogyn.org

atrophy, and the vulvar epithelium isreduced to a few layers of mostly intermediateand parabasal cell types. The labiaminora and majora as well as the clitorisgradually become less prominent with age.The skin of the vulva consists of bothdermis and epidermis, which interact witheach other and respond to different nutritionaland hormonal influences. Forexample, estrogen has little effect on vulvarepidermis, but considerable effect onthe dermis, thickening the skin and preventingatrophy.Postmenopausal atrophic changes canbecome a clinical problem when a womanresumes sexual intercourse after a long periodof abstinence, as in the opening case. Ifatrophy is the main complaint, estrogenreplacement therapy will alleviate symptomsof tightness, irritation, and dyspareunia, butit may take 6 weeks to 6 months to achieveoptimal results. In the interim, women needto be reassured that reasonable function canbe achieved.Hygienic considerationsWith any vulvar irritation, the patientshould discontinue the use of syntheticundergarments in favor of cotton panties,which permit more adequate circulationand do not trap moisture.Sitz baths often help relieve local discomfort,but should be followed by thoroughdrying.❚ Vulvar dystrophies:Think “white”In the past, these diseases have beendefined as non-neoplastic epithelial disordersof the vulva. Although there havebeen many attempts to more accuratelydefine vulvar dystrophies, none have completelydescribed the wide variety of clinicalpresentations.In general, dystrophies are disorders ofepithelial growth and nutrition that oftenresult in a white surface color change. Thisdefinition includes intraepithelial neoplasiaand Paget’s disease of the vulva. TheACOG opinion on vulvodyniaThe new ACOG Committee Opinion reflects recommendationsof the American Society for Colposcopy and Cervical Pathology. 17• Vulvodynia may be localized or generalized. Painlocalized to the vulvar vestibule, formerly termed vulvarvestibulitis, is now classified as localized vulvodynia.• The cause is unknown, and therefore it cannot bedetermined whether localized and generalized vulvodyniaare different manifestations of the same disease orcompletely different entities.• Treatment can be difficult, and improvement can takeweeks or months, even with appropriate therapy.– No single agent is successful in all women– Pain may never subside completely– Patients may need us to help them developrealistic expectations for improvement• Some women need psychological support, such assex therapy and counseling.Vulvodynia. American College of Obstetricians and Gynecologists CommitteeOpinion No. 345. Obstet Gynecol. October 2006;108:1049–1052.International Society for the Study ofVulvovaginal Disease has proposed multipleclassifications since 1975. I prefer theclarity of the 1987 classification system. 1 Ialso consider these terms out-of-date:lichen sclerosus et atrophicus, carcinomasimplex, leukoplakic vulvitis, leukoplakia,hyperplastic vulvitis, neurodermatitis,kraurosis vulvae, leukokeratosis, erythroplasiaof Queyrat, and Bowen’s disease.What makes the lesions white?The white appearance of dystrophiclesions is due to excessive keratin, at timesdeep pigmentation, and relative avascularity.All 3 of these characteristics are presentin the spectrum of vulvar dystrophies.Biopsy of the affected skin is the key toaccurate diagnosis and successful therapy.FAST TRACKVulvar dystrophies❙ Lichen sclerosus❙ Squamous cellhyperplasiaFormerly “hyperplasticdystrophy”❙ Other dermatosis❙ Squamous cellcarcinoma in situMay present clinicallyat any age as papulesor macules, coalescent ordiscrete, single or multiple❙ Paget’s diseaseof the vulvaClinicopathologic entitywith a pathognomonichistologic appearanceSource: Modified from Voet RL 1❚ Lichen sclerosusDoes not raise risk of carcinomaThe most common of the 3 groups ofwhite lesions described in the 1987 classificationof dystrophies, lichen sclerosususually occurs in postmenopausal women,but can appear at any age, including childwww.obgmanagement.comDecember 2006 • OBG MANAGEMENT 63