Gynae: Lichen Sclerosus and Atrophic Vaginitis

Question 1

what is atrophic vaginitis?

Answer 1

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

occurs in women entering menopause

Question 2

what is the pathophysiology of atrophic vaginitis?

Answer 2

epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions

as oestrogen levels fall, resulting in mucosa becoming thinner, less elastic and more dry

tissue more prone to inflammation

changes to vaginal pH and microbial flora that have contributed to localised infections

lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence

Question 3

how does atrophic vaginitis present?

Answer 3

itching

dryness

dyspareunia

bleeding due to localised inflammation

also consider in women with recurrent UTI, stress incontinence, pelvic organ prolapse

Question 4

what will examination of the vagina and labia show?

Answer 4

• Pale mucosa
• Thin skin
• Reduced skin folds
• Erythema and inflammation
• Dryness
• Sparse pubic hair

Question 5

how is atrophic vaginitis managed?

Answer 5

vaginal lubricants

topical oestrogen - cream, pessaries, tablets, rings

Question 6

what are some contraindications for topical oestrogen?

Answer 6

breast cancer

angina

VTE

unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer

woman should be monitored at least annually with a view to stopping treatment whenever possible

Question 7

what is lichen sclerosus?

Answer 7

chronic inflammatory skin condition that presents with patches of shiny procelain-white skin

Question 8

what areas are commonly affected by LS?

Answer 8

labia

perineium

perianal skin

can also affect axilla, thighs can affect man on foreskin and glans of penis

Question 9

pathophys of LH

Answer 9

thought to be autoimmune and associated with other autoimmune diseases (T1DM, alopecia, hypothyroid, vitiligo)

Question 10

how is Lichen Sclerosus diagnosed?

Answer 10

clinical diagnosis based on history and examination

vulval biopsy to conform diagnosis

Question 11

what is lichen simplex? do not confuse with lichen sclerosus

Answer 11

chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin

presents with excoriations, plaques, scaling and thickened skin

Question 12

what is lichen planus? do not confuse with lichen sclerosus

Answer 12

autoimmune condition causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae

Question 13

how does lichen sclerosus present?

Answer 13

typically aged 45-60

can be asymptomatic

• itching
• soreness and pain possibly worse at night
• skin tightness
• painful sex
• erosions
• fissures

Question 14

what is the Koebner phenomenon?

Answer 14

when signs and symptoms are made worse by friction to the skins

occurs with lichen sclerosus

can be made worse by tight underwear that rubs skin, urinary incontinence and scratching

Question 15

what is the appearance of lichen sclerosus?

Answer 15

• looks like a figure of 8
• “Porcelain-white” in colour
• Shiny
• Tight
• Thin
• Slightly raised
• There may be papules or plaques

Question 16

how is lichen sclerosus managed?

Answer 16

cannot be cured

symptoms control

potent topical steroids - dermovate, used long term. initially every day, then frequency reduced. used more frequenctly for flares. 30g tube should last at least 3 months

emollients - used regularly with steroids then without as maintenance

Question 17

what are the complications of lichen sclerosus?

Answer 17

5% risk of developing squamous cell carcinoma on the vulva

pain, discomfort, sexual dysfunction, bleeding, narrowing of vaginal or urethral openings