Is It Possible To Have Transient Vaginal Dryness During The Changes In Menopause

Vulvovaginal changes later on menopause

Vulvovaginal atrophy occurs due to decreasing oestrogen levels

Oestrogen is the master hormone that regulates the physiology of the vulvovaginal tissues. As a woman ages, the progressive decline in circulating oestradiol, first in the peri-menopausal menses, results in a number of changes that can affect the health of the genitourinary tract. The inherent sensitivity of the vulvovaginal peel, progressive oestrogen deficiency and the close proximity of the urethral opening and the anus, combined with skin changes due to ageing make conditions affecting the vulvovaginal skin mutual and a crusade of distress for many mail service-menopausal women.

For farther information, see: "Skin and the biology of ageing".

Changes that occur with increasing age and decreasing oestrogen levels include:¹

Atrophy of vulval tissues – thinning of the skin, atrophy of subcutaneous fat, decreased hair growth
Atrophy of the vagina – narrowing and shortening of the vagina with constriction of the introitus. The lining of the vagina tends to get thinner, less elastic and smoother due to a decrease in the rugal folds
Atrophy of all other oestrogen-dependent tissues, e.thousand. pelvic floor muscles, urethral mucosa, uterus, ovaries
Decreased vascularity
Decreased vaginal secretions
Alterations in the vaginal microflora – decreased glycogen from vaginal epithelial cells results in a change in the pH of the vagina from acidic to more basic (typically > five.0). The change in pH is detrimental to the survival of acid-producing bacteria (eastward.one thousand. lactobacilli) and can atomic number 82 to further alterations in the pH and the microflora.

Vulvovaginal atrophy is the term used to draw the specific atrophic changes of the vulva and vagina that occurs progressively in all women after menopause. It is also regarded as a condition in itself because the characteristic changes due to failing oestrogen tin result in a range of symptoms, such equally vaginal dryness, irritation and discomfort. The atrophic changes likewise make the vulvovaginal skin more vulnerable to trauma and infection.¹

Other vulvovaginal conditions become more common after menopause

In addition to vulvovaginal cloudburst, a number of other conditions get more common afterwards menopause, such equally vulval dermatitis, lichen sclerosus and less frequently, lichen planus. Lichen simplex may also occur in mail service-menopausal women, withal, it is more frequently observed in younger women. The pattern of symptoms from these atmospheric condition can often exist similar, with the majority of women having itch every bit their primary symptom. The not-specific nature of the presenting symptoms, withal, tin can make distinguishing between the various atmospheric condition difficult.

In some women, more than i vulval condition may exist present simultaneously or there may be a more than generalised underlying dermatological condition, e.thousand. psoriasis. Itching from a primary dermatosis may lead to scratching and excessive use of hygienic measures, leading to secondary lichen simplex and irritant contact dermatitis. Other diagnoses should exist considered, therefore, if an initial treatment regimen has failed to produce an improvement in symptoms.² Making a diagnosis tin exist difficult in some patients, so it is mostly recommended that referral to a Dermatologist or a Gynaecologist (preferably with a special interest in vulval dermatoses) should exist considered for confirmation of a diagnosis if the vulval disorder has failed to respond to initial handling.

Atrophy of oestrogen-dependent tissues can contribute to other gynaecological bug for women who are post-menopausal, including uterine prolapse, urinary incontinence (see: "Incontinence is a take chances factor for skin lesions") and recurrent urinary tract infections (see: "Recurrent UTIs").³ Women who are mail service-menopausal may besides continue to have issues with vulvovaginal candidiasis and bacterial vaginosis.

For various reasons, sexually transmitted infections (STIs) are often not considered as a diagnosis in older women.^four However, many post-menopausal women remain sexually agile and may take a higher run a risk of STIs due to increased susceptibility to infection (as a result of atrophic alter) and a lack of rubber employ, particularly in women who are "newly single".^{4, 5} Women may also have concerns about sexual role, as this can be affected past vulvovaginal atrophy and vulval skin conditions (run into: "Sexual wellness for older women").

Ask about vulvovaginal wellness

Many women may exist reluctant to talk about vulval or vaginal problems with a health professional person and may initially utilise over the counter products in an attempt to save vulvovaginal symptoms. It is estimated that simply 25–50% of women with vulvovaginal symptoms seek help from their General Practitioner.^{1, 6} Research has shown that at that place are many reasons why women do non inquire for assistance including:^half-dozen

The feeling that information technology is an embarrassing, uncomfortable or private thing
The conventionalities that it is a normal role of getting older
Not beingness enlightened that at that place are treatments available
Not knowing how to initiate a conversation about these issues

Acknowledging that changes in vulvovaginal health are an expected part of ageing and initiating a conversation nearly the presence of whatsoever symptoms may encourage women to share their concerns and be more receptive nearly the options for treatment.^six Some women may not reveal that they take a skin disorder affecting the vulva because they are uncomfortable or embarrassed by the need for a clinical examination of the vulvovaginal area. Their concerns should exist acknowledged and if appropriate, other options could exist offered, eastward.g. seeing a female person General Practitioner in the practise if their regular General Practitioner is male person.

The management of common vulvovaginal conditions in mail service-menopausal women

Vulvovaginal atrophy

Symptoms of vulvovaginal atrophy include irritation, vaginal dryness, dysuria and other urinary symptoms, dyspareunia and abnormal vaginal belch.^ane Atrophic vaginitis is the term often used when inflammation accompanies atrophic change, resulting in patchy redness and tenderness of the vaginal introitus.¹ In a woman with vulvovaginal atrophy without inflammation, the tissues tend to be thin, stake and dry. Fissuring of the posterior fourchette (the fold of skin forming the posterior margin of the vagina) is often seen and may likewise occur equally a upshot of even minimal stretching during vulval or vaginal examination.

Local oestrogen treatment is usually the preferred treatment pick, rather than oral or transdermal oestrogen treatment, when the sole aim of treatment is the relief of vulvovaginal symptoms.⁶ Treatment with topical oestrogens (east.chiliad. estriol 0.1% cream or 500 microgram pessaries) is regarded every bit safe and effective.ⁱⁱ The initial communication should be to utilise one application or pessary daily in the evening until there is improvement in symptoms (often ii – iii weeks) and and then to reduce the frequency to one evening, twice a calendar week.^{1, vi} The use of progestogens for endometrial protection is non usually necessary when using topical oestrogens.¹ Patients with vaginitis should be warned that initially the use of oestrogen foam or pessaries may cause stinging or burning, only that this should amend within approximately 2 weeks. A not-oestrogen containing vaginal moisturising bioadhesive gel, e.k. Replens (unsubsidised), may be used in conjunction with a topical oestrogen merely it is less constructive at relieving symptoms on its ain. A water-based vaginal lubricant may be required to convalesce vaginal dryness and friction-related trauma during sexual intercourse, still, lubricants may besides cause transient stinging or called-for if the woman has vaginitis or fissuring.¹

Uterovaginal prolapse (pelvic organ prolapse)

Women who are peri- or post-menopausal may present with symptoms due to pelvic organ prolapse. The symptoms include a dragging sensation in the pelvis, urinary incontinence or difficulties with micturition and defaecation. Examination will ordinarily reveal bulging of the vaginal walls due to prolapse of the uterus, rectum or bladder and in some women descent of the cervix (or vaginal vault in women following hysterectomy) that depending on the stage of the prolapse may extend through the introitus with straining. Treatment options include pelvic floor exercises (frequently guided by a physiotherapist), topical oestrogen, employ of a vaginal band pessary or surgery.

Vulval dermatitis

Vulval dermatitis in post-menopausal women is more than likely to be contact dermatitis due to exposure to an irritant such as soap, fragrance, over-washing or urine, than to be atopic dermatitis.² Irritants produce inflammation of the skin, which is often aggravated past vulvovaginal cloudburst, and cause itch, called-for or not-specific irritation. The clinical findings on examination may vary – a adult female with mild dermatitis may have redness, swelling and scaling of the affected area, whereas a adult female with more than severe dermatitis may have peel that is markedly cherry-red and bloated with obvious erosions or ulceration.⁷ Women with chronic dermatitis tin develop lichenification (run into: Lichen simplex, below).

Initial management relies on the avoidance of contact with irritants (come across: "Strategies to reduce vulvovaginal irritation") and the use of emollients.⁷ Low-potency topical corticosteroids, e.g. 1% hydrocortisone, can exist trialled to reduce inflammation. In women with severe itch, an oral sedating antihistamine or tricyclic antidepressant may be required at nighttime.⁷ Vaginal swabs are appropriate if there is abnormal discharge or malodour, as at that place may be co-existing infections or symptomatic bacterial vaginosis that should exist treated appropriately. The apply of topical oestrogen can increase the incidence of Candida albicans vaginitis, which is otherwise uncommon in postal service-menopausal women.

Lichen simplex

Lichen simplex arises as a result of excessive scratching and rubbing of an area affected with an underlying condition, e.g. contact dermatitis or neuropathic pruritus. This leads to lichenification of hair-bearing peel, normally on the labia majora or perineum, where the skin becomes thickened with increased skin markings and follicular prominence (Effigy one). Lichen simplex is itself intensely itchy, therefore excoriations and broken off hairs are likewise frequently seen. Pruritus results in a characteristic itch-scratch-itch cycle with symptoms often worse at night or aggravated by oestrus, humidity, soaps or the presence of urine or faeces on the affected areas.⁸ In add-on to itch, sometimes women describe a feeling of burning or hurting. Symptoms can exist intermittent or persistent and the history may extend back for months or years.⁸ Lichen simplex can occur anywhere on the body but the vulval surface area is one of a number of sites more commonly affected, others being the lower legs, forearms, wrists and the back of the scalp and neck.⁹ On the vulva, lichen simplex can be localised to one area or widespread, although mucosal or glabrous (hairless) areas are not affected.⁸

Management, which aims to reduce itch and allow healing, involves a number of steps, forth with advice on vulval intendance (run across: "Strategies to reduce vulvovaginal irritation"). The steps are to:^{9, 10}

Identify and manage the condition that has produced the primary itch, e.one thousand. dermatitis from an irritant or allergen, lichen sclerosus (see below). Neuropathic pruritus due to pudendal nerve entrapment or radiculopathy may explicate symptoms if a primary dermatosis cannot be identified.
Prescribe a sedating oral antihistamine or low-dose tricyclic antidepressant at night to break the itch-scratch-itch cycle and to assist with sleep
Prescribe a potent topical corticosteroid (e.yard. betamethasone valerate ointment) to be applied once daily to thickened peel to reduce lichenification. Reduce the authority or frequency of the topical corticosteroid every bit the plaques resolve, usually afterward four to six weeks depending on the extent and severity of lichen simplex. If handling with betamethasone valerate ointment does not appear to exist beneficial so referral to a Dermatologist is recommended. Ultra-potent topical corticosteroids such as clobetasol propionate ointment tin be used just should ideally exist prescribed only for specific indications when a diagnosis has been confirmed, and their employ should be monitored.
Explain how and where to utilise the ointment; application of potent topical corticosteroids on non-affected skin risks steroid-induced cutaneous atrophy

In addition, cool packs to control itch short-term, and emollients to reduce dryness and itch, can exist applied frequently and may be helpful. Erosions and fissures can exist acquired past scratching and, although uncommon, can predispose the patient to secondary bacterial infections which may require oral antibiotics.⁸ Treatment can often result in complete resolution of symptoms, all the same, this relies heavily on an constructive approach to the elimination of vulval irritants and beingness able to stop the itch-scratch-itch cycle. For some women, lichen simplex tin can get chronic and cause significant distress. Long-term use of a tricyclic antidepressant, and intermittent applications of topical corticosteroid ointments (e.g., every bit weekend pulses), may be required in these women.

Follow-up is essential to ensure symptoms are controlled and treatment is used effectively and safely

Strategies to reduce vulvovaginal irritation

Eliminating any aggravating factors is an important step in the direction of women with weather affecting the vulvovaginal area.⁸ Aggravating factors include scratching and rubbing, products and routines used for cleansing, exposure to urine or faeces and medicines or products used to reduce symptoms from the underlying condition.⁸ Women who are post-menopausal are more than probable to be affected by these factors than younger women, as the barrier that the vulvovaginal skin forms is more vulnerable due to oestrogen deficiency.

Women tin be advised to:^eight

Avoid scratching and rubbing if possible – non-pharmacological methods for the relief from itch include cool gel pads, refrigerated petroleum jelly on a pad or cloth, or applied directly to the vulva. Petroleum jelly also acts as a moisturiser and a bulwark grooming. It can be practical frequently. Sitting in a lukewarm bath may also be soothing. Advise women to keep their fingernails brusk or to wear gloves at night.
Wash the vulva with h2o and avoid the utilize of soaps, chimera baths, bath oils and salts or perfumed products.
Use white, unscented soft toilet paper – some of the inks on the printed papers can irritate skin. Avert using baby or personal wipes; these wet products take a high-concentration of preservatives (such as methylisothiazolinone) to which contact allergy is increasingly reported.
Tell their doctor if they have urinary incontinence then that this can be treated. Ensure pads or underwear designed for incontinence are used rather than pads intended for menstrual utilize. If leakage occurs, ideally the urine should be rinsed off the vulva with water followed by the application of petroleum jelly to provide a barrier.
Vesture comfortable underwear and avert pantyhose. Avoid wearing underwear at nighttime unless specific incontinence products are required.
Avoid using over-the-counter products on the genital area, e.g. topical antifungal medicines or douches, equally these can cause pain or irritation and may alter normal or desirable vaginal microflora

Lichen sclerosus

Lichen sclerosus is an inflammatory skin disorder, thought to be of autoimmune origin, but with influences from genes, hormones, irritants and infection.^{eight, xi} It can occur in women of any historic period, but nigh frequently in those anile over 50 years.¹¹ Lichen sclerosus primarily affects the glabrous (hairless) vulval, perineal and perianal skin only does not involve the vagina itself. Longstanding illness tin can extend to involve the labia majora and inguinal folds. Approximately 10% of women with vulval lichen sclerosus will also have non-genital areas of skin afflicted,^xi and upwards to 20% may have some other autoimmune disease, such as thyroid dysfunction, vitiligo, psoriasis or pernicious anaemia.^{8, 11}

The nigh common symptom in women with lichen sclerosus is severe itch, although many are asymptomatic. Women may too complain of pain, which may exist aggravated by the development of fissures secondary to scratching or friction from sexual intercourse. Chronic lichen sclerosus can cause distortion of the genital beefcake, including adhesions, resorption or partial fusion of the labia minora, and narrowing of the vaginal introitus causing dyspareunia compounded past postal service-menopausal changes from atrophy and loss of elasticity.^eight Scarring and crevice development around the anus can crusade pain or bleeding and beal constipation.

On examination, the afflicted areas of skin may appear white and thickened and there may exist ecchymoses, petechiae or purpura (Figure 2). Scratching can result in fissures and, rarely, secondary infection.

Referral to a specialist in vulvovaginal disease (unremarkably a Dermatologist or a Gynaecologist with an interest in vulval disorders) is recommended for confirmation of the diagnosis and, when management is circuitous, shared long-term care. Information technology is not e'er easy to distinguish lichen sclerosus from other conditions affecting the vulval area and a biopsy is ofttimes required for an authentic diagnosis. Lichen sclerosus is rarely curable, although can usually be improved, therefore it is important that a long-term plan is established for treatment and follow upwardly.⁸ In improver, lichen sclerosus is associated with the development of vulval intraepithelial neoplasia (VIN) and invasive squamous prison cell carcinoma, with an incidence of approximately five%.⁸ In women with lichen sclerosus, ideally the vulval skin should exist reviewed at least annually, or more than often if symptoms persist despite treatment, so that an alternative diagnosis can be considered or if malignancy develops it is detected early (encounter: "Malignant vulval skin lesions"). Education is essential to explain the long-term nature of the disorder, the need for on-going, at least intermittent, treatment and follow-up.

Treatment with a potent or ultra-potent topical corticosteroid ointment, e.g. betamethasone valerate ointment or clobetasol propionate applied at nighttime to affected areas for upwardly to three months, is the usual initial option and is aimed at reducing symptoms to a tolerable level.⁸ Ensure that the adult female is aware of the specific areas of afflicted skin that should be treated. The duration of daily treatment depends on the initial severity and the response to treatment. The frequency of application or potency of the topical corticosteroid should then be slowly reduced once the symptoms take begun to settle, east.thousand. used one to three times a week. More limited use of a stiff or ultra-potent corticosteroid (e.chiliad. a maximum of two weeks) is recommended in women with lichen sclerosus affecting the perianal peel because this is more susceptible to thinning.^viii

The majority of mail service-menopausal women with vulval lichen sclerosus should besides be treated with intravaginal oestrogen foam. The response to corticosteroid treatment tin can be quite variable, with itch reducing within a few days but the appearance of the skin not returning to normal for weeks or months.¹¹ Maintenance treatment is required in many women, e.g. a topical corticosteroid used on a weekly basis, to prevent reoccurrence of symptoms and reduce the progression of scarring.^eight If scarring has already occurred, this is not reversible with corticosteroid handling. If in that location is narrowing of the vaginal introitus, the use of vaginal dilators can be trialled. These are used progressively, starting with a small size and increasing in size equally tolerated. Surgery is sometimes the best treatment option, particularly if the woman experiences difficulties with micturition (due to labial fusion causing obstruction of the urethra) or if the utilise of vaginal dilators has non resolved problems with sexual intercourse.^8,eleven

Incontinence is a adventure factor for pare lesions

The presence of urine and/or faeces on the skin creates an alkaline pH due to leaner digesting urea and producing ammonia.¹⁴ This increases the activeness of proteases and lipases which tin can cause peel irritation and dermatitis.^xiv Peel breakup becomes more likely in older women if their skin remains moist for extended periods. Vulvovaginal atrophy, scratching and inappropriate cleansing can exacerbate this problem by further diminishing the skin'southward barrier function.

For further data, run across: "Urinary incontinence in adults", BPJ 55 (Oct, 2013)

Recurrent UTIs are more than mutual in older women

Older women are more than susceptible to recurrent urinary tract infection (UTI) due to factors such as vulvovaginal atrophy (which increases take chances of trauma and infection), incontinence, utilize of catheters and living in a residential intendance setting. It is estimated that each year viii% of postmenopausal women will have a UTI and iv% may have recurrent infections.³

Asymptomatic bacteriuria is very common in older women and does not require antibiotic treatment (or testing). The diagnosis of UTI in older women should therefore be made based on clinical signs and symptoms, likewise equally the results of urine culture. Urine culture should be requested in older women who have recurrent infection, or signs of pregnant infection such as fever > 38°C, worsening urgency or frequency, suprapubic hurting, urinary incontinence or gross haematuria.

For some women recurrent urinary tract infections may be prevented past the use of topical oestrogen treatment.^three

Lichen planus

Women with vulval lichen planus may nowadays with itch and hurting, like to the symptoms of lichen sclerosus, however, it is less mutual than lichen sclerosus, is more probable to touch on other areas of the body and also affects mucosal pare, e.thou. of the vagina and rima oris.¹² Lichen planus, like lichen sclerosus is also thought to be an inflammatory pare status of autoimmune origin. Lichen planus most often affects women from age 30 – 60 years.¹⁰

The severity of vulval lichen planus tends to vary depending on the subtype. Subtypes include a cutaneous form (purplish or dark-brown papules in pilus-bearing areas), a mucosal form (painless, often itchy, white streaks) or the more than common erosive form, affecting the vaginal introitus, characterised by marked redness and erosions with a characteristic white hyperkeratotic edge (Effigy three).^{8, 13} Erosive lichen planus can result in astringent distortion and scarring of the afflicted areas with pain rather than itch being the master symptom.^{ten, 12} Dissimilar lichen sclerosus, lichen planus ofttimes affects the vaginal mucosa causing a encarmine vaginal belch.

The diagnosis of lichen planus can often exist made based on the history and clinical findings, however, it is recommended that women be referred to a specialist in vulvovaginal affliction for confirmation of the diagnosis, normally with biopsy although the histopathology may be nonspecific. The histological changes in lichen planus are often subtle and site-dependent with central areas less likely to show classical features than the samples taken from the margins.^xiii In addition, as with lichen sclerosus, there is a gamble of development of vulval malignancy and the condition tin can be more challenging to manage.^{8, 12, thirteen}

Initial handling for lichen planus is the same every bit for lichen sclerosus, but some women may require oral corticosteroids or immunomodulatory medicines, such equally methotrexate, if the use of topical corticosteroids has non improved their symptoms.^{x, 12}

Seborrhoeic dermatitis and psoriasis in mail-menopausal women

Although more than ofttimes diagnosed in younger women, seborrhoeic dermatitis and psoriasis may affect women of any age. These two weather condition may occur simultaneously and when they are difficult to distinguish, "sebopsoriasis" may be diagnosed.

Seborrhoeic dermatitis tends to affect skin folds (due east.g. inguinal, crural and interlabial creases), and hair-begetting areas (east.m. mons pubis, labia majora, perianal areas) and causes mild symptoms such equally crawling, scale and fissuring. Almost women with seborrhoeic dermatitis give a history of pityriasis capitis (dandruff) and seborrhoeic dermatitis affecting the scalp, eyebrows, retroauricular and nasolabial folds where they take ill-defined pinkish, flaking patches. Seborrhoeic dermatitis is treated with intermittent awarding of a topical antifungal (e.thousand., ketoconazole shampoo, twice weekly in the shower) and a low-potency topical corticosteroid (e.thou., 1 % hydrocortisone cream) when symptomatic. This combination works well for seborrhoeic dermatitis, but is less constructive for sebopsoriasis, which may require short term treatment with more potent corticosteroids (see below).

Psoriasis affecting the vulvovaginal area can be part of a more than widespread type of psoriasis (usually plaque psoriasis), however, in ii – 5% of patients, it may bear upon the genital area only.^{15, 16} Women with psoriasis of the vulvovaginal area frequently present with well-circumscribed, vivid red plaques that are symmetrically distributed in the vulva.¹⁵ Other flexural sites are also commonly afflicted, e.g. natal cleft, omphalus, axillae and under the breasts or an abdominal apron (if the flexures are involved it is referred to as flexural psoriasis).¹⁶ Itch tin vary from minimal to astringent. On test, scale can be a prominent feature, but it is often absent in moist areas resulting in a shiny smooth appearance to the affected peel (Figure 4). Psoriasis can be colonised by bacteria and yeasts, leading to symptomatic maceration and fissuring.

Treatment is normally with intermittent courses of low to moderate potency topical corticosteroids.^xv Flexural psoriasis usually responds well to the use of topical corticosteroids, however, it is often recurrent and may require repeated but intermittent apply of a topical corticosteroid.¹⁶ Pedagogy is therefore essential to explicate to women that psoriasis tends to recur or that it may persist and to ensure that they use topical corticosteroids safely. Topical corticosteroids are absorbed to an increased extent by genital skin and this tin result in thinning of the skin.¹⁵ The employ of more potent topical corticosteroids should be limited to a few weeks only and stepped downward to a less stiff corticosteroid in one case the psoriasis is improving.^fifteen

Stronger topical treatments used for psoriasis affecting other parts of the torso (e.g. dithranol foam, coal tar preparations) may be too irritating for employ in the vulvovaginal expanse, although they can be used for short periods and washed off or diluted in an emollient.¹⁵ Oral medicines (east.g. methotrexate) are usually not required for psoriasis that is limited to the genital area, and the use of phototherapy should exist avoided.^xv

Less common vulvovaginal weather in post-menopausal women

Mucous membrane pemphigoid (or cicatricial pemphigoid)

This is a rare autoimmune affliction that causes blistering of mucous membranes, e.g. of the rima oris, middle, nose and vulva.¹⁷ It ordinarily affects older people (historic period > lxx years) and is more common in women.¹⁷ When it involves the vulva information technology can cause severe scarring resulting in distortion of the vulval anatomy.^xviii Clinically it may be difficult to distinguish from other atmospheric condition affecting the vulva, such as lichen sclerosus or erosive lichen planus. Referral to a vulvovaginal specialist is recommended for an authentic diagnosis because although mucous membrane pemphigoid can respond to a potent topical corticosteroid it is often a very difficult condition to treat successfully and requires oral corticosteroids or an immunosuppressant medicine.¹⁷

Pemphigus vulgaris is another baking autoimmune disease that can affect the genital area although more commonly the oral mucosa. Vulval pemphigus is extremely rare in New Zealand.

Malignant vulval skin lesions

About malignancies involving the vulval area occur in mail-menopausal women, although vulval intraepithelial neoplasia (VIN) may brainstorm prior to menopause and is occasionally diagnosed in younger pre-menopausal women.¹⁹ VIN has the potential to progress to invasive carcinoma of the vulva and women with suspicious lesions require referral to secondary or tertiary care for biopsy and treatment. Approximately 90% of vulval cancers are squamous cell carcinomas (Figure 5), however, other types of malignant lesion may occur in the vulval surface area including, melanoma, basal prison cell carcinoma, sarcoma and rarely, Paget disease of the vulva (below) and adenocarcinoma of the Bartholin gland.^twenty

Compared to benign dermatoses, malignant lesions are usually asymmetrical, unifocal or multifocal papules, plaques, erosions and ulcers. As with malignant lesions elsewhere on the body, those on the vulva typically take an irregular shape, structure, color and distribution. Well-nigh vulval cancer starts in glabrous or mucosal sites rather than in cutaneous areas.²⁰ Many women with malignant lesions of the vulva do not present with an obvious mass. Symptoms of vulval cancer vary with the extent and the specific type of cancer involved. For example, itch or pain are associated with squamous cell carcinoma in approximately fifty% of women, lesions due to Paget disease of the vulva may cause a called-for sensation and itch, while other women with malignant lesions may exist asymptomatic.²⁰ Women with symptomatic vulval invasive cancers may present with itch, an obvious lump, pain, ulceration or bleeding.

Women with suspicious lesions or those that take non responded to treatment for atmospheric condition, such as lichen sclerosus should be referred urgently to a specialist for examination, biopsy and further investigations every bit appropriate. Take chances factors for vulval cancer include smoking, VIN, lichen sclerosus, lichen planus, cervical cancer or intraepithelial neoplasia, previous HPV infection and positive HIV status.^xx Vaginal or anal intraepithelial neoplasia (VAIN, AIN) or invasive cancer of the vagina and anus are less common than vulval malignancy.

Paget disease of the vulva

Paget disease of the vulva (also referred to as extramammary Paget disease) is a rare malignant status, primarily affecting older women, that can be difficult to distinguish clinically from other skin conditions affecting the vulva.²¹ The clinical features include crawling and sometimes pain arising from thickened areas of peel around the vulva that get red, scaly and crusted (Figure 6).

Typically, the skin lesions will have been present for some fourth dimension as initially they are asymptomatic or cause modest irritation only. If Paget disease is suspected, referral to a vulvovaginal specialist is recommended because an authentic diagnosis relies on the results of a biopsy. Other investigations, e.g. colposcopy or pelvic imaging, are likely to exist required because there is an association with other underlying malignancies. For instance, Paget affliction around the anus is associated with an underlying colorectal cancer in approximately 25 – 35% of people.²¹

Management usually involves surgical excision of the lesion, withal, recurrence is common (up to fifty%) and farther surgery is oft required.^{ten, 21} Mohs micrographic surgery is the preferred option, if it is available, as it is associated with lower rates of recurrence and less extensive surgical excision.^{10, 21} Non-surgical treatments include the use of laser ablation, topical fluorouracil, imiquimod or photodynamic treatment.^{10, 21}

Benign skin lesions

A number of benign skin lesions may be found in the vulvovaginal area including:

Seborrhoeic keratoses: appear as "stuck on" warty papules on hair-bearing peel. They are benign but may be symptomatic or confused with malignant lesions. Removal (due east.m. shave/curette/diathermy or cryotherapy) is mostly only indicated if the lesions are painful, increasing in size or to rule out malignancy (excisional biopsy).

Peel tags (acrochordon, soft fibroma): appear equally pendulous lesions on a narrow stem. More mutual in areas of friction (medial thighs), and in women who are obese. Removal past shave excision or cryotherapy is simply necessary if painful irritation or inflammation occurs.

Epidermal inclusion cysts: are common on the pilus-bearing skin of the labia majora. Treatment is just required if the cyst becomes infected (with incision and drainage, and an oral antibiotic if appropriate) or if the cyst is large and symptomatic when surgical excision is usually required, provided whatever infection has settled.

Melanocytic naevi (moles): typically appear as skin- to dark-coloured, soft macules or papules. They are by and large under 6 mm in diameter, and uniform in shape, colour and construction. However, naevi that are larger, irregular in shape or colour are not uncommon in pubic or genital sites. Examine the patient's overall pattern of naevi to determine whether a item spot is different from others, i.east. an ugly duckling. If uncertain, conform dermatoscopic examination by an skillful (usually a Dermatologist). Removal is only necessary for cosmetic reasons or to exclude malignancy.

Angiokeratomas: are solitary or more ofttimes multiple cherry, purple, bluish or blackish papules <five mm, located on labia majora. Women may present with these lesions considering of bleeding or painful thrombosis, or because they are alarmed by the advent. Reassurance is appropriate. Larger lesions can be distinguished from malignant lesions because of their uniform shape, structure and colour. Dermatoscopy reveals single or multiple red, purple or blue clods (lacunes) unless thrombosed, when they are blackness (and soon resolve).

Lipomas: appear as a freely moving, well-defined, sub-cutaneous mass. Excision is only indicated if painful, increasing in size or to exclude malignancy. They are rare in the vulvovaginal region.

For further information and images of these lesions, see: www.dermnetnz.org

Sexual wellness for older women

Questions about sexual wellness are a routine aspect of general practice. While this is most usually considered in younger patients, it is important that sexual health is discussed with all patients, regardless of their historic period. The purpose of a sexual health history is non only to assess risk of sexually transmitted infections, but also to identify bug with sexual function and to appraise overall wellbeing and knowledge virtually sexual health.

Talking about sexual health tin be awkward or embarrassing for women of all ages so it is important to ensure that the patient feels comfy and that the tone of the consultation is appropriate. Consider using an opening argument such equally "We routinely discuss sexual health with all our patients, is it ok if I ask y'all some questions?" This could exist followed by more direct questions that can lead into a more detailed give-and-take virtually sexual health in older females:

Are you lot sexually agile?
Do yous have any questions or bug with sex that you would similar to talk over?

Sexual response and what is considered normal varies from person to person. In general, a sexual health dysfunction should exist but considered a problem if it causes distress to the person or their partner. For instance, vaginal dryness or loss of libido may not be an issue for a woman who is not sexually agile, still, if the adult female meets a new partner, this may be something she seeks assistance for.

Sexual problems for older women may include:

Loss of libido; identify any contributing factors such equally medicines or unmanaged co-morbidities, offering referral for counselling
Vaginal discomfort and dryness; recommend utilise of lubricant or consider use of topical oestrogen
Vaginal/vulval hurting; investigate and treat any crusade, recommend apply of lubricant, pelvic floor exercises
Incontinence; manage symptoms and modifiable factors, recommend incontinence wear, pelvic flooring exercises
Consequence of co-morbidities and medicines on sexual function; where possible, reduce doses or avoid medicines which decrease libido, eastward.one thousand. antidepressants, manage co-morbidities
Lack of privacy, e.grand. in a residential intendance setting; encourage discussion with carers
Cocky-esteem issues; encourage give-and-take and coping strategies, offer referral for counselling
Human relationship issues, e.thou. new partner, pressure to have sex; encourage discussion, consider referral for counselling
Inadequate knowledge near STIs; brainwash well-nigh STIs, testing, appropriate protection and possible symptoms

The North American Menopause Society has produced a useful resource for women experiencing sexual health issues after menopause, available from: http://world wide web.menopause.org/for-women/sexual-wellness-menopause-online

General Practitioners with an interest in the area of vulvovaginal wellness may wish to bring together the Australian and New Zealand Vulvovaginal Society, which holds an almanac conference and update meetings for wellness professionals. Their website provides a listing of specialists with an interest in vulval disorders, information about upcoming meetings and conferences, website links and patient data about vulval disease. Come across: www.anzvs.org

Too see: "Vulvovaginal health in pre-menopausal women", BPJ 41 (Dec, 2011).

Source: https://bpac.org.nz/bpj/2014/september/vulvovaginal.aspx

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