In an article published in the March 2017 issue of Mayo Clinic Proceedings, Mary L. Marnach, M.D., a gynecologist, and Rochelle R. Torgerson, M.D., Ph.D., a dermatologist, both at Mayo Clinic in Minnesota, offer successful treatment options for postmenopausal women with vulvovaginal conditions. These therapies address chronic, uncomfortable vulvovaginal conditions that may interfere with sexual intercourse and lead to cancer. They also discuss lichen simplex chronicus, lichen sclerosus and lichen planus.
I'm Mary March back. I'm one of the o p g. I s here at the Mayo Clinic. I'm Michelle Torture said I'm a dermatologist here at the Mayo Clinic, and we're here today to talk to you about our article Volvo Vaginal issues in Mature Women. The article is a result of us working together, You know, Evolve, our dermatology clinic that we've had together over the past few years. It's worked out very well because we can combine our expertise, uh, to take care of women with challenging vocal vaginal issues as they age. So the article starts out talking about a very common thing that we see in gynecology, especially called the genital urinary syndrome and menopause. We used to call it bubble vaginal atrophy. Um, and the reason that name was switch were because of a two organizations in the United States and worldwide decided that it should be renamed. Um, I think they gave it a gentler name, but essentially, it comes down to a very common condition in women as they age. Um, we know that at least 50% of women, as they get into menopause will complain about things like painful sex vaginal dryness, irritation with urinating, that sort of thing, and that can very much be helped by using vaginal estrogen, which is usually applied to the vagina and topically, to the N treatise or the opening of the vagina, Um, twice per week. The problem is that when you look at this overall, only about 7% of women tend to use their vaginal estrogen like we recommend. But it's still probably is the best therapy that we have for that condition. And so we're big advocates of that. The article then goes on to talk about three of the conditions that are often seen not only by gynecologist but dermatologists as well. And those are liken sclerosis, likened Simplex Cronicas, which is a bit of a variation of a dermatitis as well as like unpleasantness. The first two are by far the most common Black and planets is much less common, starting with lichens simplex cronicas. This is thought to be the result of a multifactorial irritation of the skin. It simply gets to the point where probably a little bit of one thing, such as dryness, with a little bit of maybe irritation from a soap or laundry detergent starts to snowball to the point that women get impressive itch and a good itch scratch cycle that is hard to break develops. Women are very uncomfortable and have, like in simplex Cronicas, and one of the key things in their history is they may scratch at night when they don't even know they're doing that. Or they may wake up at night having blood on their underclothes. We suggest for those patients that we address any irritants that can be removed and then treat with a mid to high potency topical cortical. Steroids liken. Sclerosis is a disease that also has it, but it's a slightly different type of itch. It's not an itch where someone is driven as much to scratch. Liken sclerosis is unfortunate, though, because it can be a progressive disease. We can get architectural alteration and liken sclerosis that can lead to despair. Ania or DC area and patients with liken sclerosis of the vulva do have an increased risk for squamous cell carcinoma of the vulva. Somewhere in the range of about 5%,, it isn't very important to identify these women to develop a treatment plan. The gold standard for treatment is close to zero appointment and then to realize that not only do you treat in the acute setting, but you need to develop an ongoing maintenance program for these women. So I think it's really important at the beginning of treating these women to explain to them this is a chronic condition and therefore it needs chronic therapy. Lifelong So often the patient stops the medication, and that's the wrong thing to do. In working with Dr Torgersen as well, I've learned that it's important to realize we can use long term, high dose steroids in an appointment form to the vulva and even inter vaginally on a long term basis. We just tend to cut back the usage to about 2 to 3 times weekly if the disease is quite stable. But it's a common thing for doctors not to understand that they can continue those steroids in ointment for long term to the balls without a risk. And and it really helps slow down the architectural changes, as Dr Gerson mentioned and then also treats the disease. We're also starting to get results from research that show that with chronic ongoing management, we seem to reduce the overall risk for squamous cell carcinoma. So the condition at the end that we talk about is, I think, one of the most challenging that I see in gynecology called like complaints. It's rare, thank goodness, but for the women that get it, it's very debilitating. So it's important that we're able to recognize the condition and we've included pictures of that so that the clinician can understand what it looks like because often patients will tell us together that they have seen numerous physicians and providers who didn't realize they were looking at like complaints. And unfortunately, it's also an autoimmune condition that's chronic. It can be treated, but it can't be cured. And it causes significantly erosive changes to the opening of the vagina, as well as inter vaginally and about 70% of women that develop it. And I think it's important to recognize, too, that they can have it in other areas of the body, so it really can be sort of a systemic looking disease. But it is so important to get the woman to buy into again things like clo beta cell therapy or tackle emails that are going to be very helpful to use long term, it again to carries the risk of about 3 to 5% chance of malignancy, so it needs to be followed very closely and treated aggressively. Management of like implants can often involve multiple physicians. That has to do with the fact that it can affect multiple areas. So as far as genital disease like implants can affect the vulva on the external genitalia. But it can also affect the vagina. Other areas. Scalp and hair, skin, eyes, ears, mouth, trachea, esophagus, fingernails and toenails. And so it's important when you're seeing a patient with, like implies, to make sure you ask about these other areas. Often, if a patient is coming to you as a provider about a genital condition, they aren't going to spontaneously share with you concerns about these other areas of their body. And I think it's so important to realize in women, too, that they'll often present to us with some closing of the vagina and explain that they can no longer have intercourse, which we can imagine would be life altering. And so again, aggressive therapy is important. Sometimes will attempt to open up that stenosis through some of our euro gynecology colleagues, although the like of planets is without a doubt the most challenging of these diagnoses, both in making a diagnosis and managing the disease. The first three conditions we talk about are typically a little more straightforward and often if you have a good initial treatment plan in place relatively easy to manage their the types of things that primary care providers should feel comfortable diagnosing and treating. And with that said, if they've treated the patient and they're not responding, we are very happy to see them to deal with this together because we do see the more complex and challenging cases. I think it's important at first to recognize that these conditions, while they're challenging to treat they, are treatable. We have good therapies, even though we can't hear them. I think it's important to educate the patient as best we can. I would say there are probably 22 roadblocks in a way to helping patients with these diseases. Sometimes it's actually getting them to someone who understands that the disease is manageable. Sometimes patients will hear what we can't do anything for that, and I think that's true and that we can't cure it. But It's certainly not true. As far as management, we can help patients manage the disease. The next roadblock is what Dr Martin referred to earlier, which is that there is a lot of misunderstanding about the use of high potency corticosteroids. Patients will get feedback from many directions, sometimes from their pharmacists, when they go to fill their prescription, sometimes from another physician who sees that they have the long term use of a steroid on their medication list. And it simply is important to understand that different areas of our body and skin respond to corticosteroids differently. So when we're treating these genital diseases were applying the high potency critical steroid to mucous membrane. Mucous membrane is very resistant to side effect from high potency corticosteroids. If we use a treatment plan where we use it frequently in the beginning to gain control and then back off our frequency for maintenance, we can use these types of medications long term without running into side effects. So in addition to the use of the corticosteroid, I feel fairly strongly as a gynecologist with the topical estrogens are also helpful being used along with the steroids, so many of our patients use both both the topical estrogen as well as a corticosteroid appointment. The interesting thing is that the topical estrogen estrogen, I think, have come back into play more years ago, it was thought that those were treatment for these diseases. We now understand they don't treat the disease. But I like to describe to patients that once we use the estrogen, we really get more youth and poof and resilience back into those tissues, so it makes it easier for us to manage the disease with our corticosteroids. Therefore, women can go on, and many of them with these conditions can have comfortable intercourse. And they really get part of their life back that they might have been missing. We hope you found this presentation from the content of Mayo Clinic proceedings valuable. Our journal's mission is to promote the best interests of patients by advancing the knowledge and professionalism of the physician community. If you are interested in more information about us, our homepage is www dot mayo clinic proceedings dot org. There you will find access information for our social media content, such as additional videos on our YouTube channel or journal updates on Facebook. You can also follow us on Twitter. More information about health care at Mayo Clinic is available at www dot mayoclinic dot org. This video content is copyrighted by Mail, Foundation for medical education and Research.