Disclosures

The Older Woman with Vulvar Mark Spitzer, MD Itching and Burning „ Merck: Advisory Board , Speakers Bureau Mark Spitzer, MD „ QiagenQiagen:: Speakers Bureau Medical Director „ SABK: Stock ownership Center for Colposcopy „ Elsevier: Book Editor Lake Success, NY

Old Adage Does this story sound familiar?

„ A 62 year old woman complaining of vulvovaginal itching and without a discharge self treatstreats with OTC miconazole.miconazole. „ If the only tool in your tool „ Two weeks later the itching has improved slightly but now chest is a hammer, pretty she is burning. „ She sees her doctor who records in the chart that she is soon everyyggthing begins to complaining of itching/burning and tells her that she has a look like a nail. yeast infection and gives her teraconazole cream. „ The cream is cooling while she is using it but the burning persists „ If the only diagnoses you are aware of „ She calls her doctor but speaks only to the receptionist. She that cause vulvar symptoms are Candida, tells the receptionist that her yeast infection is not better yet. „ The doctor (who is busy), never gets on the phone but Trichomonas, BV and atrophy those are instructs the receptionist to call in another prescription for teraconazole but also for thrthreeee doses of oral fluconazole the only diagnoses you will make. and to tell the patient that it is a tough infection.

„ A month later the patient is still not feeling well. She is using cold compresses on her vulva to help her sleep at night. „ She makes an appointment. The doctor tests for BV. The „ Desperate to get rid of an annoying and frustrating test comes back positive for Gardnerella and beta Strep. patient, her doctor refers her to me. The doctor treats her with vaginal clindamycin cream for a “bacterial infection”. I see these patients every day „ After a few more phone calls to the doctor resulting in „ When the patient comes into my office she lists as her “telephone treatment for self diagnoses” she returns to the chief complaint ‘chronic yeast infection’ doctor. „ The first thing I tell her is that in order to get to the „ The doctor sees nothing except atrophy that would be typical for a woman of this age, so he treats her with bott om o f her pro blem, we will fi rst h ave t o di scard vaginal estrogen cream. every diagnosis she has had in the past and that she „ The patient is now worse than ever. She Googles ‘yeast may not have a yeast or bacterial infection at all. infections’ and finds all sorts of books, articles and chat „ She asks me “if it is not a yeast infection, what else rooms full of horror stories. She goes on a restrictive diet could it be?” and begins to lose weight. She washes her vulva with antibacterial soap twice daily to keep it clean and uninfected. She begins to down acidophilus pills by the fist full. She now begins to experience a little itching and a slight cheesy That is what this lecture will be about discharge in addition to her burning (which is worse than ever).

1 Learning Objectives Vulvodynia

„ Often a silent disease At the conclusion of this lecture the participant should be able to: „ 30% of women with these conditions will suffer without seeking medical care „ Describe the main differential diagnosis of vulvar burning irritation , rawness , stinging „ Many doctors are unfamiliar with other causes or pain in an older woman. vulvar itching, burning and pain so they treat „ Describe the main differential diagnosis of what they know vulvar itching in an older woman „ Typically, these women are told they have: „ Know the treatment of conditions that „ Yeast infection cause itching and burning of the vulva in „ Bacterial vaginosis an older woman „ Vaginal atrophy

Before We Start, Some Before We Start, Some Foundational Principles of Candida Foundational Principles of BV in the in the Older Woman Older Woman „ Candida thrives in a well estrogenized,estrogenized, glycogenated „ BV is estrogen dependent. Postmenopausal women who vagina and absent certain risk factors, Candida is quite are not on HRT or vaginal estrogen rarely get BV unusual in women with vaginal atrophy „ The symptoms are a vaginal discharge with a foul or „ Risk factors: fishy odor . Itching and/or irritation are less common. „ Hormone replacement (especially vaginal estrogen) „ Because G. vaginalis is normally found in the vagina, a „ Immune suppression (steroids, immune suppressive “detected” result using a nucleic acid probes for G. medications, HIV) Vaginalis (Affirm VPIIIVPIII),), although suggestive, is not

„ DM (especially poorly controlled DM) definitive proof of BV. ResultsResults should be interpreted in conjunction with other test results and clinical findings. „ In older women, Candida is often not associated with a creamy or cheesy discharge and is much more likely to Amsel’s criteria areare useful teststests to support a diagnosis of be nonnon--albicansalbicans yeast that may be resistant to BV. fluconazole.

Candidiasis

Differential diagnosis Differential diagnosis Trichomoniasis for symptoms for symptoms including: including: Bacterial vaginosis DISCHARGE DISCHARGE ITCHING ITCHING Atrophic vaginitis BURNING BURNING

2 Herpes Aphthosis Group A IBD - Crohns genitalis (complex) streptococcus

Contact Chlamydia Gonorrhea An Approach to the Evaluation dermatitis

Psoriasis Candidiasis of Vulvar Pain and Burning (and

Lichen Differential diagnosis Trichomoniasis Itching) simplex chronicus for symptoms

Dry skin including: Bacterial vaginosis „ Causes Eczema DISCHARGE „ Lichen ITCHING Atrophic On the skin sclerosus vaginitis BURNING „ Of the skin Paget’s Desquamative Inflammatory disease vaginitis „ Neither (diagnosis of exclusion)

Vulvar intraepithelial Erosive Lichen neoplasia / Neoplasia Planus

Vulvodynia Vulvodynia Abscess - Hidradenitis localized general MRSA Suppurativa

On the Skin „ Candida Contact Dermatitis

„ Trichomoniasis (usually burning and irritation) „ The unestrogenized vulva is more „ HSV (usually pain, burning or irritation) susceptible to irritants and allergens „ ?Strep vulvovaginitis? than the estrogenized vulva of „ Contact dermatitis (irritants or allergens ) someone who is of reproductive age „ No matter how the patient describes her symptoms, irritative symptoms are almost always vulvar (not vaginal) and treating the vagina will not be as effective as treating the vulva directly

Vulvar Eczema: Allergic Contact Dermatitis Allergic or Irritant Dermatitis

„ Much less common than irritant contact „ Thickened or red excoriated skin dermatitis „ Skin changes may be minimal „ Usually very itchy „ When no other cause of itching can be found, assume „ May have previous exposure without an the cause is eczema allergic reaction „ Distinction between irritants „ May happen hours to days after the exposure and allergens is difficult and not necessary „ Findings in acute allergic contact dermatitis „ Thin skin is more easily irritated „ In keratinized skin (diaper rash/post menopausal „ Well demarcated edema, papules, vesicles skin) and crusts „ Irritated skin is more easily irritated „ In mucous membrane „ Less well demarcated edema and erosion

3 Approach to ‘On the Skin’ Vulvar Care Measures

Vulvar Care Measures „ Use very mild soap for bathing the rest of the body. No Avoid contact with potential irritants soap on the vulva. „ Frequent baths with soaps may increase the irritation „ Soap „ Sanitary products, especially panty „ Adult or baby wipes liners, incontinence pads „ You cannot wash away your symptoms antiseptics „ Conditioners „ Colored or scented toilet „ Tea tree oil „ Vaginal odor and vulvar symptoms are rarely a hygiene pppaper „ Topical anesthetics (e .g . problem and will not get better by washing more or „ Condoms (lubricant or benzocainebenzocaine,, lidocainelidocaine,, dibucainedibucaine)) spermicide containing) „ Topical antibacterials (e.g. washing more vigorously. „ Contraceptive creams, jellies, neomycin, bacitracin,bacitracin, polymyxin)polymyxin) „ Wear white 100% cotton underwear; No underwear at foams, nonoxynolnonoxynol--9,9, „ Topical antifungal preparations lubricants, (e.g. imidazolesimidazoles,, nystatinnystatin)) night; washed only in hypoallergenic detergent with no „ Dyes „ Topical corticosteroids fabric softeners or dryer sheets. „ Emollients (e.g. lanolin, jojoba „ Other topical medications, oil, glycerin) including trichloroaceticacid, 5-5- „ No pantyhose or other tight-tight-fittingfitting clothes. „ Laundry detergents, fabric fluorouacil, Podofilox or softeners, and dryer sheets podophyllinpodophyllin)) „ Put underwear through an extra plain water rinse „ Rubber products (including „ Vaginal hygiene products latex) (including perfumes and deodorants)

Lichen Simplex Chronicus Of the Skin (Hyperplastic Dystrophy, Squamous Hyperplasia) „ Lichen simplex chronicus /squamous cell hyperplasia (end stage of vulvar eczema) „ End stage of the „ Lichen sclerosus itchitch--scratchscratch--itchitch „ Lichen planus cycle of vulvar „ Psoriasis eczema „ VIN „ Years of relentless „ Paget's disease chronic itching: „ Fissuring “nothing helps” „ Any acute or chronic condition that causes edema or thickening of the skin can cause fissuring

Lichen Simplex Chronicus Lichen Simplex Chronicus

„ Skin is thick (and often red)

„ Caused by intense repetitive rubbing and scratching

„ May exhibit erosions or fissuring

4 LSC and Treatment of LSC

Squamous „ Eliminate irritants Cell Cancer „ Steroid creams (ointments if the skin is broken) „ Triamcinolone 0.1% BID for mild changes, fluocinonide 0.05% or clobetasol 0.05% for severe changes „ RhkiRecheck in one month thfi for signs of ft atroph y, super infection or steroid rebound dermatitis „ Treat/suppress yeast with weekly fluconazole „ Nighttime sedation with amitriptyline (produces deep sleep without scratching), diphenhydramine or hydroxyzine (produces REM sleep only and has no intrinsic antianti--itchitch properties except for urticaria)

Lichen Sclerosus Lichen Sclerosus

„ „ Chronic dermatologic condition. Symptoms include vulvar „ Etiology - unknown itching, burning, (?autoimmune?) dyspareunia, pain with „ Epithelial thinning, distinctive skin changes and defecation. inflammation. „ Biopsy may indicate only „ Very common condition. inflammation or minimal „ Can occur at any age but primarily in postmenopausal epithelial change early in women and prepre--pubertalpubertal disease. children (5-(5-1515%).%). „ „ 33--5%5% lifetime risk of vulvar No vaginal involvement. CA.

Clinical Findings in Lichen Sclerosus Lichen Sclerosus: Presentation „ Pathognomonic sign is texture change. Thin, white, finely wrinkled, keratinized skin (figure-(figure- ofof--88 pattern). „ Loss of vulvar architecture „ Loss of labia minora. „ Clitoris buried by fusing overlying skin. „ Keyhole opening „ Fissures „ Excoriations

5 Treatment of Lichen Sclerosus Results of Treatment of LS

„ Clobetasol 0.05% cream or ointment BID x 6 weeks „ 96% complete or partial relief. „ Recheck after 6 weeks „ 23% resolution to normal texture, color. continue until the texture of „ 68% partial resolution of hyperkeratosis, the skin has normalized not purpura, fissuring, erosions. just the color or the Bornstein et al. Am J OG 1998;178:80. symptoms Cooper et al. Arch Dermatol 2004;140:702 „ Decrease gradually as „ Conflicting evidence on value of maintenance symptoms demand but never „ Monitor 3 and 5 mos. following initial therapy. to zero „ Annual exams for women with well-well-controlledcontrolled LS. „ 30 gm. tube should last approximately 33--66 monthsmonths.. „ More frequent visits for those with poorly controlled disease. „ Estrogen cream is useless „ Conclusion: Advise patients to return if change in „ Testosterone cream is useless symptoms especially new growths or ulcers. and potentially harmful ACOG Practice Bulletin, No. 93. Obstet Gynecol 2008:111:1243.

Results of Treatment of LS Erosive Lichen Planus

„ Unknown etiology (?autoimmune?) „ Age range: 29 - 68 „ Symptoms: Itching, pain, burning, "raw" sensation, dyspareunia „ 2/3 of patients with vulvar disease develop mucous membrane disease „ 20% of patients have only PiPrior t o t reat ment 6 weeks mucous membrane disease „ Vestibule may be red, eroded and tender and may be friable and have adherent exudate „ End stage disease -bands,- bands, resorption of labia minora, obliteration of clitoral hood and atrophy (similar to lichen sclerosis) introitus may be stenotic 14 weeks 20 weeks

Erosive Lichen Planus Erosive Lichen Planus:

„ 1% of the general population has oral lichen planus.planus. 25% of Presentation those have genital disease „ Physical Findings „ Oral disease „ Lacy linear papules with painful erosions in the posterior buccal mucosa (may bleed easily) „ Vulvar disease „ Mild - fine subtle white Look for the presence interinter--lacylacy papules ƒ of a narrow white Image courtesy NVA „ Severe --erosiveerosive border at the epithelium at the periphery of the vestibule (sometimes eroded area. Classic Presentation surrounded by white Subtle Presentation “lacy” epithelium)

6 Desquamative Inflammatory Vaginitis Lichen Planus: Presentation „ May be a vaginal variant of erosive lichen planus „ Etiology unknown (?autoimmune?) „ Clinical presentation: „ Copious discharge that may have been ppy(yresent for years (often yellowellow--gg,reen, but may be bloody). „ May be associated with vulvarburning, irritation and itching. „ Intercourse is often uncomfortable or painful. „ Looks like severe atrophic vaginitis

Zoon’s (Plasma Cell) Vulvitis

Desquamative Vaginitis (2) Treatment of Lichen PlanusPlanus/DIV/DIV „ Physical examination: „ Lichen planus „ Denuded vaginal epithelium „ Mild disease - 1% hydrocortisone or 0.1% triamcinalone „ Purulent exudate cream „ Most reliable finding is red „ Severe disease patches in vagina that mimic „ 25 mg hydrocortisone suppositories t.i.d. for 11--22 months postmenopausal atrophy then once daily or 1/2 in the morning and 1/2 in the with trauma evening for 1 -22months months or „ Vaginal Microscopy: basal cells, lots of poly's, „ Bursts of oral prednisone 40-40-7070 mg/day X 22--66 weeks „ Alternative treatment for vaginal lichen planus high pH, no lactobacilli „ Tacrolimus 0.1% suppositories for vaginal disease; „ Cultures –Candida Tacrolimus 0.1% ointment for vulvar disease (negative), bacterial „ DIV „ Hydrocortisone 100 mg/gram in clindamycin 2% emollient (mixed flora) cream base „ Insert 5 gram (applicator full) every other day x 14 doses

Vulvodynia Epidemiology of Vulvodynia A Diagnosis of Exclusion: „ Vulvar pain may affect as many as 15% of 1 „ Exclude everything we have discussed so women 2 far „ A 2003 study found that: „ Nearly 40% of women choose not to seek treatment, „ Physical exam including vulvar colposcopy „ Of those who did seek treatment, 60% saw 3 or more doctors, many of whom could not provide a diagnosis. „ Vaginal wet prep and cultures

„ Therapeutic trial of avoiding irritants „ If the patient is not better, assume vulvodynia

1. Jones and Lehr :Nurse Pract 1994;19:34,371994;19:34,37--4646 2. Harlow and Stewart: J Am Med Womens Assoc 2003;58:82-2003;58:82-8.8.

7 Vulvodynia Localized Vulvodynia (Vestibulodynia (Vestibulodynia))

„ Generalized „ „ Provoked (sexual, nonsexual, Severe pain on or both) vestibular touch or attempted vaginal „ Unprovoked penetration

„ Mixed (provoked and unprovoked) „ Tenderness to pressure ◄ ◄ localized within the „ Localized (vestibulodynia, clitorodynia, vulvar vestibulitis, vulvar vestibule

vestibular adenitis, „ Only physical findings ◄ ◄ hemivulvodynia, etc.) may be varying degrees „ Provoked (sexual, nonsexual, of erythema or both) „ Colposcopy may be „ Unprovoked helpful (skip the acetic acid) „ Mixed (provoked and unprovoked)

Localized Vulvodynia(Vestibulodynia (Vestibulodynia)) Cause of Vulvodyniaand

„ May occur at any time in a woman’s VestibulodyniaVestibulodynia:: Theories life including before coitarche. „ Pain, burning, stinging, irritation or „ Genetic predisposition to having more rawness at the vaginal opening with inflammatory cells and fewer antiinflammatory attempts at intercourse, tampons, cells in the skin. riding a bicycle, tight jeans, horsebackhorseback--riding,riding, jogging, etc. „ The inflammation causes proliferation of

„ Symptoms often begin after nociceptive (pain) nerve fibers in the skin and experiencing some type of infection makes the skin more sensitive to pain. or trauma. Many women have been „ As a result, these women experience pain to a told they have a “chronic yeast stimulus that is painless to everyone else. infection” „ May be associated with interstitial cystitis or fibromyalgia

Sequential Treatment of Vestibulodynia 1. Vulvar care measures „ Cotton 2. Topical anesthetics (e.g. swab testing 5% lidocaine ointment) 3. Tricyclic antidepressants „ Diagram (e.g. amitriptyline) or antianti-- may be convulsants (e.g. helpful in gabapentin) (orally or compounded into a vulvar assessing cream) the pain 4. Biofeedback and physical over time therapy 5. Surgery (vestibulectomy(vestibulectomy with vaginal advancement) (high success rates of 70%+). usually a last resort. Reserve surgery for PURE vestibulodynia

8 Generalized Vulvodynia - Symptoms Generalized Vulvodynia -Treatment - Treatment

„ Burning, irritation, rawness, pain (not related to „ Vulvar care measures touch or pressure) without evidence of erythema, „ Low dose tricyclic antidepressants inflammation or other dermatopathology „ Start at 10 mg; increase every 7-7-2121 days „ May be intermittent or constant „ Side effects include: drowsiness, dry mouth and eyes, „ May be similar to a UTI (e.g. frequency, constipation, urinary retention, loss of libido or the urgency, dysuria) but with negative cultures abilityyg to have an orgasm, increase in app pp(getite (weight „ Periods of unexplained relief and/or flares gain) (side effects decrease with time) „ Older patients may also have rectal discomfort „ Anticonvulsant drugs (e.g. Gabapentin, Pregabalin) or chronic low back pain „ Start at 300 mg (100 mg in older women); increase „ May be related to fibromyalgia, interstitial every 3-3-77 days cystitis, urethral syndrome or pudendal „ Side effects include: sleepiness and dizziness and less commonly GI symptoms and mild leg swelling. May neuralgia cause or increase balance problems and increase cognitive impairment in older women „ Discontinue medication GRADUALLY

Psychological Distress Important Things to Remind Your Patients About Vulvar Pain

„ It is rarely associated with cancer. „ It is rarely caused by an STD and is not contagious.

„ Even if we can’t prove what is causing the pain, we can treat it.

„ It is not due to poor hygiene. In fact strong soaps and detergents can make the condition worse.

Important Things to Remind Your Important Things to Remind Your Patients About Vulvar Pain (2) Patients About Vulvar Pain (3)

„ There is nothing wrong with you as a „ It didn’t develop overnight; it won’t go away overnight. person; the problem is your pain. „ Don’t feel that because this is ggpenital pain „ Treatment setbacks may occur . that you can’t talk to other people. People „ A setback may be due to the same with chronic problems need others for condition or another condition with similar support. Family and friends can help. symptoms. I can’t tell over the phone. You have to come in. „ If you are in a relationship, both of you are affected by this problem. Appropriate „ We understand that chronic pain is couple counseling may be needed. exhausting and can be demoralizing.

9 Thank You

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