Post Menopausal Vulvar Lesions
Apr 2009 – by P. DiSaia, MD
In the post menopausal period the vulvar skin may undergo changes which are grouped together under the heading of dystrophies or dysplasia sometimes termed vulvar intraepithelial neoplasia (VIN). It is often difficult to make a correct diagnosis because many of these lesions present as a whitening of the skin. Biopsy is essential and there are several instruments that can be used. Probably the instrument that gives the best specimen for the pathologist is the Keyes biopsy blade which cores out a circular piece of skin which is easy for the pathologist to orient.
A common benign condition which can occur at any age but is more common in the post menopausal patient is lichen sclerosus. The microscopic features of lichen sclerosus include hyperkeratosis, epithelial thickening with flattening of the rete pegs, cytoplasmatic vacuolization of the basal layer of cells and the appearance of a collagenous tissue beneath the epidermis which is relatively a cellular. Edema is occasionally seen and these patients often present with purtitus.
Lichen sclerosus is not a premalignant lesion, but about 5% of patients will have or develop cancer of the vulva. Clobetasol is considered the treatment of choice for Lichen Sclerosis and has replaced testosterone propionate topical preparations as the most effective therapy. If Clobetasol is not successful, other options would be etretinate and pimecrolimus.
A similar lesion called squamous cell hyperplasia presents in the same manner with intensive itching. White patches are frequently seen along with evidence of excoriation. Biopsy reveals an increase on the thickness of the top layer of the epidermis (hyperkeratosis) and irregular thickening of the Malpighian layer (acanthosis). This latter process produces a thickened epithelium as well as a lengthening and distortion and of the rete pegs. Squamous cell hyperplasia is also a condition of unknown ideology and it too responds to the use of high strength topical cortical therapy. Clobetasol ointment appears to be the treatment of choice. Cessation of topical steroid therapy results in a reoccurrence of symptoms so most clinicians recommend reducing frequency of application as the condition improves but in the main both Lichen sclerosus and squamous cell hyperplasia are life long conditions.
Vulvar intra epithelial Neoplasia (VIN) can develop in women of any age. As a matter of fact its frequency appears to be increasing among younger women. Today, the average age for VIN is said to be about 50 years of age. The presence of a distinct mass, bleeding or discharge, strongly suggests invasive cancer and not VIN. VIN is often asymptomatic and presents as a whitening or hyperpigmentation of what appears to be normal vulvar skin. Over half of the women have multiple lesions all thought to be related to HPV virus infection. The lesions are located in the non-hairy portion of the vulva in 85-95% of cases. Once again, biopsy is essential to confirm the diagnosis and distinguish it from the benign lesions described above. Surgical excision has been the mainstay of therapy. Other clinicians have utilized laser vaporization of the epithelium especially when lesions appear on vital structures such as the glans clitoris. Recurrences are frequent and patients should be monitored closely. Fortunately the progression to invasive disease is usually quite slow. Patients with VIN will have a 60% chance of associated CIN and those patients with CIN will have up to a 10% chance of associated VIN.
The International Society for the Study of Vulvar Disease has recommended strongly that previously used terms such as Lichen sclerosus et atrophicus, leukoplakia, neurodermatitis, Bowen's disease, hyperplastic vulvitis, Kraurosis vulva and erythroplasia of Queyrat all be discontinued from use as they are essentially all terms for the three conditions described above.