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MARY MARNACH: I'm Mary Marnach. I'm one of the OBGYNs here at the Mayo Clinic.

ROCHELLE TOGERSON: I'm Rochelle Togerson. I'm a dermatologist here at the Mayo Clinic. And we're here today to talk to you about our article "Vulvovaginal Issues in Mature Women."

MARY MARNACH: The article is a result of us working together in a vulvar dermatology clinic that we've had together over the past few years. It's worked out very well because we can combine our expertise to take care of women with challenging vulvovaginal issues as they age. So the article starts out talking about a very common thing that we see in gynecology especially called the genitourinary syndrome of menopause.

We used to call it vulvovaginal atrophy. And the reason that name was switched were because of two organizations in the United States and worldwide decided that it should be renamed. I think they gave it a gentler name. But essentially, it comes down to a very common condition in women as they age.

We know that at least 50% of women, as they get into menopause, will complain about things like painful sex, vaginal dryness, irritation with urinating, that sort of thing. And that can very much be helped by using vaginal estrogen, which is usually applied to the vagina and topically to the introitus, or the opening of the vagina, twice per week. The problem is that when you look at this overall, only about 7% of women tend to use their vaginal estrogen like we recommend. But it still probably is the best therapy that we have for that condition, and so we're big advocates of that.

ROCHELLE TOGERSON: The article then goes on to talk about three of the conditions that are often seen not only by gynecologists, but dermatologists as well. And those are lichen sclerosus, lichen simplex chronicus, which is a bit of a variation of a dermatitis, as well as lichen planus. The first two are by far the most common. Lichen planus is much less common.

Starting with lichen simplex chronicus, this is thought to be the result of a multifactorial irritation of the skin. It simply gets to the point where probably a little bit of one thing, such as dryness, with a little bit of maybe irritation from a soap or a laundry detergent starts to snowball to the point that women get impressive itch. And a good itch-scratch cycle that is hard to break develops.

Women are very uncomfortable that have lichen simplex chronicus, and one of the key things in their history is they may scratch at night when they don't even know they're doing that. Or they may wake up at night having blood on their underclothes. We suggest for those patients that we address any irritants that can be removed, and then treat with a mid- to high-potency topical corticosteroid.

Lichen sclerosus is a disease that also has itch, but it's a slightly different type of itch. It's not an itch where someone is driven as much to scratch. Lichen sclerosus is unfortunate, though, because it can be a progressive disease. We can get architectural alteration in lichen sclerosus that can lead to dyspareunia or dysuria.

And patients with lichen sclerosus of the vulva do have an increased risk for squamous cell carcinoma of the vulva, somewhere in the range of about 5%. It is very important to identify these women to develop a treatment plan-- the gold standard for treatment is clobetasol ointment-- and then to realize that not only do you treat in the acute setting, but you need to develop an ongoing maintenance program for these women.

MARY MARNACH: So I think it's really important at the beginning of treating these women to explain to them that this is a chronic condition. And therefore, it needs chronic therapy lifelong. So often the patient stops the medication, and that's the wrong thing to do. In working with Dr. Togerson as well, I've learned that it's important to realize we can use long-term, high-dose steroids in an ointment form to the vulva and even intervaginally on a long-term basis.

We just tend to cut back the usage to about two to three times weekly if the disease is quite stable. But it's a common thing for doctors not to understand that they can continue those steroids in ointment form long term to the vulva without a risk. And it really helps slow down the architectural changes, as Dr. Togerson mentioned, and then also treats the disease.

ROCHELLE TOGERSON: We're also starting to get results from research that show that with chronic ongoing management, we seem to reduce the overall risk for squamous cell carcinoma.

MARY MARNACH: So the condition at the end that we talk about is, I think, one of the most challenging that I see in gynecology called lichen planus. It's rare, thank goodness. But for the women that get it, it's very debilitating. So it's important that we're able to recognize the condition. And we've included pictures of that so that the clinician can understand what it looks like, because often patients will tell us together that they have seen numerous physicians and providers who didn't realize they were looking at lichen planus.

And unfortunately, it's also an autoimmune condition that's chronic. It can be treated, but it can't be cured. And it causes significantly erosive changes to the opening of the vagina, as well as intervaginally in about 70% of women that develop it. And I think it's important to recognize too that they can have it in other areas of the body. So it really can be sort of a systemic-looking disease.

But it is so important to get the woman to buy into, again, things like clobetasol therapy or tacrolimus that are going to be very helpful to use long term. It, again, too carries the risk of about 3% to 5% chance of malignancy, so it needs to be followed very closely and treated aggressively.

ROCHELLE TOGERSON: Management of lichen planus can often involve multiple physicians. That has to do with the fact that it can affect multiple areas. So as far as genital disease, lichen planus can affect the vulva on the external genitalia, but it can also affect the vagina.

Other areas-- scalp and hair skin, eyes, ears, mouths, trachea, esophagus, fingernails, and toenails. And so it's important when you're seeing a patient with lichen planus to make sure you ask about these other areas. Often if a patient is coming to you as a provider about a genital condition, they aren't going to spontaneously share with you concerns about these other areas of their body.

MARY MARNACH: And I think it's so important to realize in women too that they'll often present to us with some closing of the vagina and explain that they can no longer have intercourse, which we can imagine would be life-altering. And so, again, aggressive therapy is important. Sometimes we'll attempt to open up that stenosis through some of our urogynecology colleagues.

ROCHELLE TOGERSON: Although the lichen planus is, without a doubt, the most challenging of these diagnoses, both in making a diagnosis and managing the disease, the first three conditions we talk about are typically a little more straightforward, and often, if you have a good initial treatment plan in place, relatively easy to manage. They're the types of things that primary care providers should feel comfortable diagnosing and treating.

MARY MARNACH: And with that said, if they've treated the patient and they're not responding, we are very happy to see them to deal with this together, because we do see the more complex and challenging cases. I think it's important at first to recognize that these conditions, while they're challenging to treat, they are treatable. We have good therapies, even though we can't cure them. I think it's important to educate the patient as best we can.

ROCHELLE TOGERSON: I would say there are probably two roadblocks, in a way, to helping patients with these diseases. Sometimes it's actually getting them to someone who understands that the disease is manageable. Sometimes patients will hear, well, we can't do anything for that. And I think that's true in that we can't cure it, but it's certainly not true as far as management. We can help patients manage the disease.

The next roadblock is what Dr. Marnach referred to earlier, which is that there is a lot of misunderstanding about the use of high-potency corticosteroids. Patients will get feedback from many directions, sometimes from their pharmacist when they go to fill their prescription, sometimes from another physician who sees that they have the long-term use of a steroid on their medication list. And it simply is important to understand that different areas of our body and skin respond to corticosteroids differently.

So when we're treating these genital diseases, we're applying the high-potency corticosteroid to mucous membrane. Mucous membrane is very resistant to side effect from high-potency corticosteroids. If we use a treatment plan where we use it frequently in the beginning to gain control and then back off our frequency for maintenance, we can use these types of medications long term without running into side effects.

MARY MARNACH: So in addition to the use of the corticosteroid, I feel fairly strongly as a gynecologist that the topical estrogens are also helpful being used along with the steroids. So many of our patients use both, both a topical estrogen as well as a corticosteroid ointment.

ROCHELLE TOGERSON: The interesting thing is that the topical estrogens, I think, have come back into play more. Years ago, it was thought that those were treatment for these diseases. We now understand they don't treat the disease. But I like to describe to patients that once we use the estrogen, we really get more youth and oomph and resilience back into those tissues. So it makes it easier for us to manage the disease with our corticosteroids.

MARY MARNACH: Therefore, women can go on, and many of them with these conditions can have comfortable intercourse. And they really get part of their life back that they might have been missing.

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