Common Benign Chronic Vulvar Disorders

 

Am Fam Physician. 2020 Nov 1;102(9):550-557.

  Patient information: See related handout on genitourinary syndrome of menopause, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Common benign chronic vulvar conditions include genitourinary syndrome of menopause (formerly called vulvovaginal atrophy), lichen sclerosus, lichen planus, lichen simplex chronicus, and vulvodynia. Genitourinary syndrome of menopause results from the hypoestrogenic state that leads to atrophy of normal vulvar and vaginal tissues. It is typically treated with lubricants, moisturizers, and intravaginal estrogen. Lichen sclerosus is an inflammatory condition characterized by intense vulvar itching. It is treated with topical steroids or, in some cases, topical calcineurin inhibitors. Patients with lichen sclerosus are at risk of vulvar squamous cell carcinoma and should be monitored closely for malignancy. Lichen planus is an inflammatory autoimmune disorder that can affect the vulva and vagina in addition to other skin and mucosal surfaces. The first-line treatment is topical steroids, and significant scarring can occur if left untreated. Lichen simplex chronicus manifests as persistent itching and scratching of the vulvar skin that leads to thickened epithelium. Breaking the itch-scratch cycle, often with topical steroids, is the key to treatment. Vulvodynia is a common vulvar pain disorder and is a diagnosis of exclusion. A multimodal treatment approach typically includes vulvar hygiene, physical therapy, psychosocial interventions, and antineuropathy medications.

Benign chronic vulvar conditions are regularly treated in primary care settings.1 This review discusses several of the most common of these conditions.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Low-dose intravaginal estrogen is the preferred hormonal treatment for vulvar manifestations of genitourinary syndrome of menopause.68

B

Consistent findings from randomized controlled trials and systematic reviews

Biopsy is indicated for patients with suspected lichen sclerosus because this condition is associated with an increased risk of squamous cell carcinoma.18,20,25

C

Findings from large epidemiologic studies and expert consensus

Patients with lichen sclerosus should be treated with a high-potency steroid ointment to alleviate symptoms, prevent architectural damage, and reverse histologic changes.2326

B

Consistent findings from large prospective studies and recommendations from evidence-based guidelines

If no underlying condition is identified as the cause of pruritus in patients with suspected lichen simplex chronicus, breaking the itch-scratch cycle is the key to therapy.2

C

Expert consensus

Treatment of vulvodynia begins with simple changes in vulvar hygiene, stress reduction, pelvic floor physical therapy, and psychosocial interventions such as cognitive behavior therapy and mindfulness-based stress reduction.48

C

Expert consensus based on prospective studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Low-dose intravaginal estrogen is the preferred hormonal treatment for vulvar manifestations of genitourinary syndrome of menopause.68

B

Consistent findings from randomized controlled trials and systematic reviews

Biopsy is indicated for patients with suspected lichen sclerosus because this condition is associated with an increased risk of squamous cell carcinoma.18,20,25

C

Findings from large epidemiologic studies and expert consensus

Patients with lichen sclerosus should be treated with a high-potency steroid ointment to alleviate symptoms, prevent architectural damage, and reverse histologic changes.2326

B

Consistent findings from large prospective studies and recommendations from evidence-based guidelines

If no underlying condition is identified as the cause of pruritus in patients with suspected lichen simplex chronicus, breaking the itch-scratch cycle is the key to therapy.2

C

Expert consensus

Treatment of vulvodynia begins with simple changes in vulvar hygiene, stress reduction, pelvic floor physical therapy, and psychosocial interventions such as cognitive behavior therapy and mindfulness-based stress reduction.48

C

Expert consensus based on prospective studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

NANCY E. RINGEL, MD, is a clinical fellow in the Division of Female Pelvic Medicine and Reconstructive Surgery at Medstar Health, Washington, D.C., and an instructor in the Department of Obstetrics and Gynecology at Georgetown University School of Medicine, Washington, D.C....

CHERYL IGLESIA, MD, is director of the Division of Female Pelvic Medicine and Reconstructive Surgery at Medstar Health and a professor in the Department of Obstetrics and Gynecology and the Department of Urology at Georgetown University School of Medicine.

Published online July 24, 2020.

Address correspondence to Nancy E. Ringel, MD, Georgetown University School of Medicine, 110 Irving St. NW, Ste. 5B-45, Washington, DC 20010. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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