Squamous vulvar intraepithelial neoplasia is seen most often in postmenopausal women but may occur during the reproductive years. Pruritus is the most common symptom, although “lumps” may be described and are sometimes confused with condyloma (268). Current terminology describes two types of VINs: VIN, usual type, that is typically HPV-related and encompassing former VIN-2 and -3 with warty, basaloid, and mixed types; and VIN, differentiated type (273). The lesion appears thickened and hyperkeratotic, and there may be excoriation. Lesions may be discrete but may be symmetric and multiple. About one-third of women will have a history of HPV related cervical disease or condyloma (268). Most women with VIN are smokers. Biopsy is necessary to confirm the diagnosis and to exclude malignancy. See Chapter 19 for management of VIN.
The urethra and vagina have a common embryonic origin and are steroid-dependent tissues. Urethral caruncles and prolapse of the urethral mucosa are examples of vulvar lesions that may be seen in other age groups but that occur more commonly among older women. Both conditions can be treated with topical or systemic estrogen preparations. Various vulvar skin lesions, including seborrheic keratoses and cherry hemangiomas (senile hemangiomas), occur more commonly on aging skin.
Up to 50% of postmenopausal women have symptoms of atrophic vaginitis (257). Symptoms include an external dysuria, pruritus, tenderness, dyspareunia, and bleeding from fissuring or ulcerations. In addition to the clinical findings of a shiny, ﬂat, thin-appearing vaginal mucosa without rugae, microscopic examination of vaginal secretions reveals an increased number of white blood cells. Treatment with local or systemic estrogens effectively manages the symptoms and restores normal pH levels with ongoing therapy (274,275). Systemic absorption does occur with topical estrogen therapy, and rates of absorption differ depending on the degree of atrophy. Topical emollients may be helpful if estrogens are not desired or are contraindicated. Vaginal lubricants are universally useful in minimizing symptoms of dyspareunia for postmenopausal women (275).
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