Vulvovaginal symptoms are common in perimenopause and menopause and might be assumed to be genitourinary syndrome of menopause (GSM). However, there are other causes of vulvar discomfort that should be considered before making the diagnosis of GSM. WHAT IS THE DIFFERENTIAL DIAGNOSIS FOR VULVAR DISCOMFORT AT MIDLIFE? Perhaps the most common vulvar condition to emerge at midlife besides GSM is lichen sclerosus.1 Additionally, existing (or undiagnosed) systemic disorders such as lichen planus or Sjogren syndrome may have vulvar manifestations that are more noticeable at midlife or appear for the first time.2,3 Lichen simplex chronicus, infection, dysplasia, and vulvodynia should also be considered.4 The increased prevalence of urinary incontinence at midlife may lead to people using incontinence protection or wipes that can cause contact dermatitis. HOW SHOULD VULVAR DISCOMFORT BE EVALUATED? The most important first step in evaluation of vulvovaginal discomfort is obtaining a history from the patient and conducting a thorough physical examination, including identifying the location of symptoms (ie, vaginal introitus vs hair-bearing vulvar skin) and the quality and severity of symptoms. The history should specifically include a comprehensive discussion of the products patients are using on the vulvar skin, as well as whether there have been any recent changes in detergents or soaps, incontinence protection products, environmental exposures, or any recent medication changes. WHAT SHOULD YOU LOOK FOR ON EXAMINATION? The differential diagnosis of vulvar disorders often begins with describing the appearance. Is the skin red, white, or darkened? Is the skin thinned or thickened? Are there raised areas (papules, plaques, vesicles) or ulcers, or is the skin flat? In some cases, the appearance is so consistent with the archetypal description that the diagnosis can be made by examination alone.4 When there are visible skin changes, taking a photo and incorporating it into the medical record can be invaluable in tracking progression or improvement. Lichen sclerosus should be considered when tissue is pale and thinned and vulvar architecture is lost. Lichen simplex chronicus should be considered when hair-bearing skin is thickened and red. Lichen planus is more often associated with pain and burning and often erythema and superficial erosion of the mucosal skin at the vaginal introitus. Contact dermatitis is most often seen as erythema in a pattern of exposure where a topical product or incontinence protection has come in contact with the skin. Vulvovaginal candidiasis may present with erythema or with minimal skin changes and a report of a feeling like there are “paper cuts.” Syphilis or herpes may present with ulcers. Dysplasia may present as a thick white plaque or a nonhealing ulcer or a mass. There is an excellent online reference for images that includes diagnostic and treatment algorithms.5 HOW CAN THE DIAGNOSIS BE DETERMINED? Dermatoses can often be distinguished by appearance, although a biopsy is the only way to definitively confirm the diagnosis. Autoimmune disorders such as Sjogren syndrome may not have visible skin changes but should be considered when a patient is having other systemic symptoms and can be evaluated via blood tests. Yeast should always be considered; diagnosis cannot be made based on examination findings, so a laboratory test should be sent. However, vaginitis panels testing for bacterial vaginosis may be misleading: none of these tests were validated for use in postmenopausal women and may give a false-positive result. Ulcers should prompt collection of a swab from the base of the ulcer for a nucleic acid amplification-based test for herpes and a serology test for syphilis. Serology testing for herpes is most useful when it is negative and is not routinely recommended. There are no tests for GSM or vulvodynia, so it is important to ensure that a thorough workup has been done before assigning these diagnoses. WHEN SHOULD A BIOPSY BE PERFORMED? Biopsy is the only way to rule out dysplasia, so it should be performed if there are any concerning features of the vulvar skin such as thickening, white plaques that cannot be wiped away, or nonhealing ulcers. It is important that a biopsy be deep enough to allow evaluation of the dermis, and in most cases, it should be performed at the edge of a lesion. It would also be reasonable to do a biopsy to confirm diagnosis of dermatoses such as lichen sclerosus or lichen planus before starting a topical steroid. Confirming the diagnosis of lichen sclerosus allows definitive counseling about the need for lifelong steroids and the slight increased risk for vulvar cancer. Vulvar lichen planus has an incomplete response to topical therapy in 20% to 40% of cases,6 and being certain about the diagnosis allows an informed transition to systemic immunotherapies if symptoms persist despite topical therapy. WHAT IF THERE IS NO DIAGNOSIS IDENTIFIED AFTER TESTING? When there are no specific findings, consider the diagnosis of vulvodynia. Unlike the vulvar and vaginal atrophic changes associated with GSM, there are no specific physical findings for vulvodynia, so it is important to ensure that a thorough workup to rule out other pathologies has been completed before assigning the diagnosis. Because exam findings may not correlate with severity of symptoms,7 patients may need reassurance that the experience of their symptoms is valid and real. Vulvodynia is an umbrella term for a constellation of symptoms that are poorly defined. Scientific understanding of genital mucosal biology and the pathophysiology of vulvar symptoms is woefully inadequate, and so many people see multiple providers before receiving a diagnosis. The diagnosis of vulvodynia is confirmed when vulvar pain persists for at least 3 months without an identifiable cause after all other conditions have been excluded. After an appropriate evaluation, providing reassurance about the lack of cancer or infection while acknowledging the frustration of not having a verifiable diagnosis may be a helpful part of management, which should be based on alleviation of symptoms. WHAT ARE GENERAL GUIDELINES FOR VULVAR CARE? The general principles of vulvar skin care include limiting irritants and hydrating the skin, as well as diagnosis-specific interventions. Practically, this means limiting use of soap in the genital area, avoiding soaps, detergents, and personal care products with fragrances or perfumes and choosing all-cotton undergarments. Skin hydration should be achieved with products that have minimal ingredients: some examples include coconut oil, olive oil, and Vaseline. KEY POINTS The differential diagnosis for vulvovaginal discomfort in postmenopausal women includes genitourinary syndrome of menopause, lichen sclerosus, lichen planus, lichen simplex chronicus, infections, contact dermatitis, vulvodynia, and dysplasia. Evaluation of vulvovaginal symptoms should include a thorough history, an examination, and review of medications and products. Examination findings may not correlate with the severity of symptoms, so patients’ concerns should not be dismissed based on a lack of changes to the vulvar appearance. CLINICAL RECOMMENDATIONS Perform a physical examination to assess vulvovaginal symptoms in postmenopausal women rather than presuming symptoms are solely because of genitourinary syndrome of menopause. Obtain a comprehensive history when evaluating vulvovaginal symptoms in postmenopausal women, documenting all products used on the vulvar skin, identifying urinary incontinence and use of pads, and noting other potential sources of irritation. Consider performing a biopsy before initiating treatment if there is a suspicion of dysplasia or dermatosis to guide selection of the most appropriate therapy. Coming next in the Step-by-Step series: Rebecca Manno, MD, MHS, adjunct assistant professor of medicine, Department of Medicine at Johns Hopkins University, reviews the differential diagnosis of arthralgia in midlife women as well as the influence of menopause and hormone therapy on common rheumatic conditions.This article is part of the ongoing series Menopause Step-by-Step, a monthly Menopause education feature.8 The Editors of this series are Dr. Cynthia Stuenkel, Dr. Cheryl Cox Kinney, and Dr. Isaac Schiff.
Caroline Mitchell (Wed,) studied this question.