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Oestrogen is the primary hormone that regulates the physiology of the vulvovaginal tissues. As a woman ages, the progressivedecline in circulating oestradiol, beginning in the peri-menopausal period, results in a number of changes that can affectthe health of the genitourinary tract. The inherent sensitivity of the vulvovaginal skin, progressive oestrogen deficiencyand the close proximity of the urethral opening and the anus, combined with skin changes due to ageing make conditionsaffecting the vulvovaginal skin common and a cause of distress for many post-menopausal women.

Vulvovaginal atrophy is the term used to describe the specific atrophic changes of the vulva and vagina that occursprogressively in all women after menopause. It is also regarded as a condition in itself because the characteristicchanges due to declining oestrogen can result in a range of symptoms, such as vaginal dryness, irritation anddiscomfort. The atrophic changes also make the vulvovaginal skin more vulnerable to trauma and infection.1

In addition to vulvovaginal atrophy, a number of other conditions become more common after menopause, such as vulvaldermatitis, lichen sclerosus and less frequently, lichen planus. Lichen simplex may also occur in post-menopausalwomen, however, it is more frequently observed in younger women. The pattern of symptoms from these conditionscan often be similar, with the majority of women having itch as their primary symptom. The non-specific natureof the presenting symptoms, however, can make distinguishing between the various conditions difficult.

In some women, more than one vulval condition may be present simultaneously or there may be a more generalised underlyingdermatological condition, e.g. psoriasis. Itching from a primary dermatosis may lead to scratching and excessive use ofhygienic measures, leading to secondary lichen simplex and irritant contact dermatitis. Other diagnoses should be considered,therefore, if an initial treatment regimen has failed to produce an improvement in symptoms.2 Making a diagnosis can bedifficult in some patients, so it is generally recommended that referral to a Dermatologist or a Gynaecologist (preferablywith a special interest in vulval dermatoses) should be considered for confirmation of a diagnosis if the vulval disorderhas failed to respond to initial treatment.

Acknowledging that changes in vulvovaginal health are an expected part of ageing and initiating a conversation aboutthe presence of any symptoms may encourage women to share their concerns and be more receptive about the options for treatment.6 Some women may not reveal that they have a skin disorder affecting the vulva because they are uncomfortable or embarrassedby the need for a clinical examination of the vulvovaginal area. Their concerns should be acknowledged and if appropriate,other options could be offered, e.g. seeing a female General Practitioner in the practice if their regular General Practitioneris male.

Women who are peri- or post-menopausal may present with symptoms due to pelvic organ prolapse. The symptoms includea dragging sensation in the pelvis, urinary incontinence or difficulties with micturition and defaecation. Examinationwill usually reveal bulging of the vaginal walls due to prolapse of the uterus, rectum or bladder and in some women descentof the cervix (or vaginal vault in women following hysterectomy) that depending on the stage of the prolapse may extendthrough the introitus with straining. Treatment options include pelvic floor exercises (often guided by a physiotherapist),topical oestrogen, use of a vaginal ring pessary or surgery.

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 skin, usuallyon the labia majora or perineum, where the skin becomes thickened with increased skin markings and follicular prominence(Figure 1).Lichen simplex is itself intensely itchy, therefore excoriations and broken off hairs are also frequently seen. Pruritusresults in a characteristic itch-scratch-itch cycle with symptoms often worse at night or aggravated by heat, humidity,soaps or the presence of urine or faeces on the affected areas.8 In addition to itch, sometimes women describe a feelingof burning or pain. Symptoms can be intermittent or persistent and the history may extend back for months or years.8 Lichensimplex can occur anywhere on the body but the vulval area is one of a number of sites more commonly affected, othersbeing the lower legs, forearms, wrists and the back of the scalp and neck.9 On the vulva, lichen simplex can be localisedto one area or widespread, although mucosal or glabrous (hairless) areas are not affected.8

In addition, cool packs to control itch short-term, and emollients to reduce dryness and itch, can be applied frequentlyand may be helpful. Erosions and fissures can be caused by scratching and, although uncommon, can predispose the patientto secondary bacterial infections which may require oral antibiotics.8 Treatment can often result in complete resolutionof symptoms, however, this relies heavily on an effective approach to the elimination of vulval irritants and being ableto stop the itch-scratch-itch cycle. For some women, lichen simplex can become chronic and cause significant distress.Long-term use of a tricyclic antidepressant, and intermittent applications of topical corticosteroid ointments (e.g.,as weekend pulses), may be required in these women.

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

Lichen sclerosus is an inflammatory skin disorder, thought to be of autoimmune origin, but with influences from genes,hormones, irritants and infection.8, 11 It can occur in women of any age, but most frequently in those aged over 50 years.11 Lichen sclerosus primarily affects the glabrous (hairless) vulval, perineal and perianal skin but does not involve thevagina itself. Longstanding disease can extend to involve the labia majora and inguinal folds. Approximately 10% of womenwith vulval lichen sclerosus will also have non-genital areas of skin affected,11 and up to 20% may have another autoimmunedisease, such as thyroid dysfunction, vitiligo, psoriasis or pernicious anaemia.8, 11

The most common symptom in women with lichen sclerosus is severe itch, although many are asymptomatic. Women may alsocomplain of pain, which may be aggravated by the development of fissures secondary to scratching or friction from sexualintercourse. Chronic lichen sclerosus can cause distortion of the genital anatomy, including adhesions, resorption orpartial fusion of the labia minora, and narrowing of the vaginal introitus causing dyspareunia compounded by post-menopausalchanges from atrophy and loss of elasticity.8 Scarring and fissure development around the anus can cause pain or bleedingand aggravate constipation.

Treatment with a potent or ultra-potent topical corticosteroid ointment, e.g. betamethasone valerate ointment or clobetasolpropionate applied at night to affected areas for up to three months, is the usual initial choice and is aimed at reducingsymptoms to a tolerable level.8 Ensure that the woman is aware of the specific areas of affected skin that should be treated.The duration of daily treatment depends on the initial severity and the response to treatment. The frequency of applicationor potency of the topical corticosteroid should then be slowly reduced once the symptoms have begun to settle, e.g. usedone to three times a week. More limited use of a potent or ultra-potent corticosteroid (e.g. a maximum of two weeks) isrecommended in women with lichen sclerosus affecting the perianal skin because this is more susceptible to thinning.8

The majority of post-menopausal women with vulval lichen sclerosus should also be treated with intravaginal oestrogencream. The response to corticosteroid treatment can be quite variable, with itch reducing within a few days but the appearanceof the skin not returning to normal for weeks or months.11 Maintenance treatment is required in many women, e.g. a topicalcorticosteroid used on a weekly basis, to prevent reoccurrence of symptoms and reduce the progression of scarring.8 Ifscarring has already occurred, this is not reversible with corticosteroid treatment. If there is narrowing of the vaginalintroitus, the use of vaginal dilators can be trialled. These are used progressively, starting with a small size and increasingin size as tolerated. Surgery is sometimes the best treatment option, particularly if the woman experiences difficultieswith micturition (due to labial fusion causing obstruction of the urethra) or if the use of vaginal dilators has not resolvedproblems with sexual intercourse.8,11 041b061a72


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