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

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

This clinical content conforms to AAFP criteria for CME.

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

Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM), formerly called vulvovaginal atrophy, is a constellation of symptoms associated with changes in vulvar and lower urinary tract anatomy due to menopause-related decreases in levels of estrogen and other hormones. Vaginal dryness and other GSM symptoms are thought to occur in approximately 50% of individuals within three years after the onset of menopause.3

PRESENTATION

Symptoms of GSM include vaginal or vulvar dryness, burning, itching, dyspareunia, bleeding, vaginal discharge, urinary urgency, and recurrent urinary tract infections. These symptoms are not often reported to physicians,4 so proactive questioning should be used to elicit whether they are present (e.g., “Do you have any questions about sex you would like to discuss today?” “Have you noticed any symptoms like vaginal pain or burning recently?”).

Although patients with GSM are by definition postmenopausal, anyone experiencing a hypoestrogenic state may have symptoms of GSM, including those who are breastfeeding, who have central (hypothalamic) amenorrhea, or who are taking medications with antiestrogenic effects (e.g., raloxifene [Evista], tamoxifen, and other selective estrogen receptor modulators; gonadotropin-releasing hormone agonists; aromatase inhibitors).

DIAGNOSIS

On examination, the vulvar epithelium of patients with GSM is typically thin, pale, and/or erythematous. Other signs include loss of vaginal rugae, introital narrowing, decreased tissue elasticity, urethral caruncle, and mucosal prolapse; resorption of the labia minora also may be apparent5 (Figure 1). Diagnosis can be made clinically based on physical examination findings alone. If litmus paper is available, the vaginal pH in untreated postmenopausal patients will be greater than 4.5. A biopsy is not required.

TREATMENT

First-line treatment for GSM involves avoidance of irritants, the use of vaginal moisturizers one to three times per week, and the use of vaginal lubricants during intercourse. However, these measures are often insufficient to resolve symptoms. If further treatment is needed, low-dose intravaginal estrogen therapy is preferred.68 Vaginal estrogen is available in the form of creams, vaginal tablets, or a vaginal ring; all are acceptable for the treatment of GSM8 (Table 1). Local estrogen administration is safe, effective, and proven to improve symptoms of atrophy and to prevent development of recurrent urinary tract infections.6,7

PreparationCommon formulationsDosing
Vaginal creams
Conjugated estrogen (Premarin)0.625 mg per 1 g of creamApply 0.5 to 2 g of cream intravaginally once per day for 21 days, then stop for seven days or apply 0.5 g intravaginally twice per week (generally start with 0.5-g dose)
Estradiol (Estrace)100 mcg per 1 g of creamApply 0.5 to 4 g of cream intravaginally once per day for two weeks, then reduce to 0.5 g twice per week
Vaginal tablet
Estradiol (Imvexxy, Vagifem, Yuvafem)Vagifem and Yuvafem: 10 mcg per tablet
Imvexxy: 4 or 10 mcg per tablet
Insert tablet into vagina once per day for two weeks, then reduce to twice per week
Vaginal ring
Estradiol (Estring)2-mg ring, released as 7.5 mcg per day over 90 daysInsert ring into vagina; replace every 90 days

Although vaginal estrogen has minimal systemic absorption; does not increase the risk of breast cancer, endometrial cancer, or venous thromboembolism9,10; and does not require concurrent use of progesterone for patients with an intact uterus, patients and physicians still may wish to avoid estrogen. This is often the case with patients who have a history of hormone-sensitive cancer, and it is good practice to consult the patient's oncologist before prescribing any hormonal medication for patients who have had breast cancer.

Alternatives to vaginal estrogen include intravaginal prasterone (Intrarosa), a synthetic form of dehydroepiandrosterone that is approved by the U.S. Food and Drug Administration (FDA) for the treatment of dyspareunia in postmenopausal patients. Prasterone also may be considered for treatment of other GSM symptoms, including moderate to severe vulvovaginal atrophy.11 Ospemifene (Osphena), an oral selective estrogen receptor modulator that is FDA-approved for the treatment of moderate to severe dyspareunia, is also effective for the treatment of vaginal dryness.12

Fractional carbon-dioxide laser therapy creates microabrasions that stimulate blood flow and thicken vaginal tissue. Small studies indicate that it is as effective as vaginal estrogen in treating symptoms of GSM.1316 However, patients should be cautioned that long-term risks of this procedure are not known, and that they should seek treatment only from physicians experienced with this procedure.

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