Anatomic changes that occur in postmenopausal women include atrophy of the labia majora and increasing prominence of the labia minora. The epithelium of the hymen and vestibule become thin; there is a shift in vaginal cellular maturation in response to estrogen deprivation, with resultant thinning. Although these changes lead to minimal symptoms in most women, external dysuria, pruritus, tenderness, dyspareunia, and bleeding can result from fissuring and excoriations. Because of the risk of VIN and malignancy, suspicious lesions require vulvar biopsy.
Vulvar Dermatoses Several vulvar conditions occur most commonly in postmenopausal women. Symptoms are primarily itching and vulvar soreness, in addition to dyspareunia.
In the past, numerous terms were used to describe disorders of vulvar epithelial growth that produce a number of nonspecific gross changes. These terms included leukoplakia, lichen sclerosus and atrophicus, atrophic and hyperplastic vulvitis, and kraurosis vulvae. The ISSVD in 2006 recommended a classification of vulvar dermatoses based on histologic patterns, listed with the likely clinical diagnoses, rather than on the basis of clinical morphology as in the previous categorization (see Chapter 19) (267). This classification system excludes neoplastic and infectious conditions. Vulvar conditions that are described in this classification system include atopic, allergic, and irritant contact dermatitis, psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, pemphigoid, aphthous ulcers, Behcet’s disease, and Crohn’s disease.
Lichen sclerosus is the most common white lesion of the vulva. Lichen sclerosus can occur at any age, although it is most common among postmenopausal women and prepubertal girls (Fig. 14.4). The symptoms are pruritus, dyspareunia, and burning. Lichen sclerosus characteristically is associated with decreased subcutaneous fat to the extent that the vulva is atrophic, with small or absent labia minora, obliteration of the anatomic landmarks, thin labia majora, and sometimes phimosis of the prepuce. The surface is pale with a shiny, crinkled pattern (described as having characteristics like “cigarette paper”), often with fissures and excoriation. The lesion tends to be symmetric and often extends to the perineal and perianal areas. The diagnosis is confirmed by biopsy. Invasive cancer is associated with lichen sclerosus, although the significance of this association is unclear in terms of causation (289).
Treatment is with an ultrapotent topical steroid such as 0.05% clobetasol. Approximately 93% of patients respond satisfactorily (269). Maintenance therapy is frequently required, and a graduated reduction from ultrapotent to medium-and low-potency topical steroids can help to maintain remission of symptoms (269–271). The topical calcineurin inhibitors pimecrolimus and tacrolimus were effective in individuals not responding to topical steroids, although the FDA approved a warning suggesting possible risk of cancer from this class of drugs and caution is thus advised with long-term use avoided (272).