UCSF Family Medicine Board Review 2013 Quiz: The “Choosing Wisely” Initiative exists for the purpose of…

Cervical Cytology and 1. Helping women choose the right method of contraception for their personal circumstances Vulvar Pathology 2. Assisting patients in deciding between medical or surgical treatments for certain conditions Michael Policar, MD, MPH 3. Listing interventions (by specialty society) for which Professor of Ob, Gyn, and Repro Sciences providers and patients should question medical necessity UCSF School of Medicine 4. Advising consumers when a brand name or generic version [email protected] of a drug is preferable based on efficacy No commercial disclosures for this lecture

Cervical Cancer Screening ACOG Cervical Cytology Guidelines ACOG Practice Bulletin #109 (2009) • Most successful cancer screening program in the US – 70% reduction in cervical cancer deaths in past 60 years Criteria Recommendation • – 2012 : 12,000 new cervical cancers; 4,200 deaths per year Women under 21 yrs old Avoid screening (regardless of age or other risk factors) • Earlier public health messages have impacted public attitudes • and behaviors...but now they need to evolve! 21-29 years old Screen every 2 years • • Advances in cervical cancer prevention since 1940s 30 to 65 or 70 years old May screen every 3 years • – Liquid-based cytology (LBC)…better test throughput 65 or 70 years old and older May discontinue screening • – hrHPV-DNA testing…co-testing and triage of test results HIV-positive Screen annually • – HPV vaccination…primary prevention of cervical cancer Immunosuppressed • Exposed in utero to DES – Evidence-based cytology screening guidelines Why Start Cervical Cytology at 21? Why Start Cervical Cytology at 21?

• Most HPV infections are transient • Invasive cervical cancer is a very rare event in women 15- • When HPV persists, transit to cancer is quite long – 19 years old. In the US from 1998-2006… CIN 3 peaks in the late 20s – – 14 cervical cancers annually Microinvasive cancer does not peak until early 40s – – When CIN 3 persists, >10 years are required for the lesion 1-2 cases per 1 million women • to acquire the capacity to become invasive In teens, screening does not reduce mortality – • Spontaneous regression is common Cervical cancer rates have not changed since 1973- – 65% rate of regression of CIN 2 after 18 months; 75% 1977, before the recommendation to screen at 18 or after 36 months first intercourse

ACOG Practice Bulletin No. 109, Dec 2009 ACOG Practice Bulletin No. 109, Dec 2009

Why Start Cervical Cytology at 21? Cervical Cytology in High Risk Women

• Consequences of over-screening and over-treatment • Women with reduced immune surveillance have faster – Emotional effect of labeling an adolescent with an STI transit times from pre-invasive to invasive lesions and a pre-cancer may affect self-image and sexuality • Do not increase the screening interval beyond annual – Possibly greater risk of preterm birth if LEEP testing for women who are – Unnecessary morbidity and expense – HIV-positive • Screening women < 21 may be harmful and lacks benefit – Immunosuppressed (transplant with anti-rejection drug) – Don’t begin until 21, regardless of first intercourse – Were exposed in utero to diethylstilbestrol P.S...ACOG Comm on Adolescent Health Care (6/2010) • Follow guidelines for women who have been treated for – If being followed for an abnormal result, continue CIN 2 or 3 or adenocarcinoma in situ

ACOG Practice Bulletin No. 109, Dec 2009 ACOG Practice Bulletin No. 109, Dec 2009 USPSTF Cervical Cytology Guidelines: 3/2012 USPSTF Cervical Cytology Guidelines: 3/2012 Moyer VA; Ann Intern Med. 2012; 156(12):880-91 Moyer VA; Ann Intern Med. 2012; 156(12):880-91

Criteria Grade Recommendation Criteria Grade Recommendation • Cytology only, 21 to 65 years old A Every 3 years • Cytology only, 21 to 65 years old A Every 3 years • HPV + cytology co-testing, 30-65 A Every 5 years • HPV + cytology co-testing, 30-65 A Every 5 years years old years old • Women under 21 yrs old D Avoid screening • Age >65 with adequate prior D Avoid screening screening and not high risk • Total ; benign disease D Avoid screening • HPV testing, alone or in D Avoid screening combination, < 30 years old

Triple A Guideline : ACS, ASCCP, Triple A Guideline : ACS, ASCCP, Am Society for Clinical Pathology Am Society for Clinical Pathology CA CANCER J CLIN March 2012 CA CANCER J CLIN March 2012

Years of Age Screening Years of Age Screening <21 No screening <21 No screening 21-29 Cytology alone every 3 years 21-29 Cytology alone every 3 years 30-65 Preferred: HPV + cytology every 5 years* OR 30-65 Preferred: HPV + cytology every 5 years* OR Acceptable : Cytology alone every 3 years* Acceptable : Cytology alone every 3 years* >65 No screening, following adequate neg prior screens After total No screening, if no history of CIN2+ in the past 20 years hysterectomy or cervical cancer ever

*If cytology result is negative or ASCUS + HPV negative *If cytology result is negative or ASCUS + HPV negative Management of Co-Testing Results Other Important Messages

• Women at any age should not be screened annually by any Cytology HPV HPV screening method Positive Negative • For women 65 and older – Negative •Co-test in 12 months, or Co-test in 5 “Adequate screening” is defined as… • • Subtype for HPV 16/18 years 3 consecutively negative results in prior 10 years, or • ASC-US Co-test in 5 2 negative co-tests, most recently within 5 years – years If screening stopped, do not restart for any reason • Women treated for CIN 2+ or AIS must be regularly screened for 20 years, even if 65 or older ASC-US/HPV negative is managed as Pap negative/HPV negative – With cytology alone Q 3 years or HPV+ cytology Q5 years

ACOG Practice Bulletin #131, Obstet Gynecol 2012;120:1222-38

USPSTF: Co-Testing Caveat Co-testing Strategy as Health Policy

• Co-testing is most appropriate for women who want to extend their screening interval to every 5 years Pros Cons But… • Slightly more accurate than • More false positives, esp. if • “Women choosing co-testing … should be aware that cytology alone done too frequently positive screening results are more likely with HPV-based • Higher negative predictive • High cost/ year of life saved strategies… and that some women may require prolonged value than cytology alone if done too frequently surveillance with additional frequent testing if they have • Longer screening interval • Many providers don’t have persistently positive HPV results” available if desired by patient EMRs to prevent overuse Summary of Cervical Cancer Guidelines Summary of Cervical Cancer Guidelines Under 21 21-29 30-65 >65 years old Hyst, Under 21 21-29 30-65 >65 years old Hyst, years old years old Years old benign years old years old Years old benign USPSTF [D] Every 3 y Co-test: Q5 None** [D] USPSTF [D] Every 3 y Co-test: Q5 None** [D] 2012 Cytology: Q3 2012 Cytology: Q3 Triple A None Every 3 y Co-test: Q5* None** None Triple A None Every 3 y Co-test: Q5* None** None 2012 Cytology: Q3 2012 Cytology: Q3 ACOG “Avoid” Every 3 y Co-test: Q5* None** None ACOG “Avoid” Every 3 y Co-test: Q5* None** None 2012 Cytology: Q3 2012 Cytology: Q3 hrHPV Never Reflex Co-test or None None test only reflex

* Preferred ** If adequate prior screening with negative results * Preferred ** If adequate prior screening with negative results

When Is a Shorter Interval Justified?

For women who… • Are in a surveillance pathway – Previously abnormal cytology result – Post-treatment with cryotherapy, LEEP, or a cone biopsy for a pre-invasive cervical lesion • Have had a result of “insufficient specimen adequacy” or an “unsatisfactory” result on her last cytology screen • Have HIV infection, a major organ transplant with the use of an anti-rejection drug, or long term corticosteroid use • Are newly enrolled in a practice and have no documented history of prior cytology results choosingwisely.org Common Questions About Pap Intervals Pelvic Exam at the Well-Woman Visit ACOG Committee opinion #534. Obstet Gynecol. 2012; 120:421-4. • Do virginal women need Pap smears? • • Are the intervals any different for women Women younger than 21 years – – With multiple sexual partners? Pelvic exam only when indicated by medical history – – Using hormonal contraceptives, menopausal hormone Screen for GC, chlamydia with vaginal swab or urine • therapy? Women aged 21 years or older – – Who only have female partners? “ACOG recommends an annual ” • No evidence supports or refutes routine exam if low risk – Who are pregnant? – If asymptomatic, pelvic exam should be a “shared decision” • If a cytology is not scheduled or necessary, what about the • Individual risk factors, patient expectations, and medico- need to perform a bimanual pelvic exam? legal concerns may influence these decisions – If TAH-BSO, decision “left to the patient” if asymptomatic The Prostate, Lung, Colorectal and Ovarian (PLCO) Ovarian Cancers: PLCO Cancer Screening RCT Cancer Screening Randomized Controlled Trial Cases Deaths Buys SS, Partridge E, et al. JAMA. 2011;305(22):2295-2303

• Randomized trial of 78,216 women aged 55-74 • Annual screening with CA-125 for 6 years + transvaginal U/S for 4 years (n=39,105) versus usual care (n=39,111) • 10 US screening centers • Followed a median of 12 years • Bimanual examination originally part of the screening procedures but was discontinued

JAMA. 2011;305(22):2295-2303

Is The “Screening Pelvic Exam” Outdated? Is The “Screening Pelvic Exam” Outdated?

Screen for Preferred test Screen for Preferred test GC, Ct NAAT: vaginal swab or urine sample GC, Ct NAAT: vaginal swab or urine sample Cervical cancer Not recommended until 21 years old Cervical cancer Not recommended until 21 years old Cytology every 3-5 years afterward Cytology every 3-5 years afterward None, if total hyst for benign disease None, if total hyst for benign disease Ovarian cancer USPSTF rec. against bimanual exam Ovarian cancer USPSTF rec. against bimanual exam Vulvar lesions Unnecessary if asymptomatic Vaginal infxn Unnecessary if asymptomatic Myomas Unnecessary if asymptomatic How Will These Changes Impact My Practice? How Can My Practice Prepare?

• The good news • Ask every patient if she also sees another provider for – With ACA, first dollar coverage of well woman visits and screening ….if so, avoid duplication of interventions cervical cytology screening • Determine the screening policies for your practice • The bad news – Make sure that all staff are aware of your policy – Since there is no national population-based educational • Inform your patients of changes that apply to them campaign, we must explain changes to our patients – During transition, discuss these decisions with patients • Systems issues – Inform patients with a personal letter or newsletter – Expect insurance benefit changes based on new guidelines • Keep track of benefit changes made by your payers – Quality indicators to measure under- and over-utilization – Few have changed screening benefits yet…but they will!

ASCCP 2012 Updated Consensus Guidelines for the Management of Abnormal Cytology Results Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors • On March 21, ASCCP released 2012 consensus guidelines for management of abnormal cervical cancer screening tests and CIN/AIS • On line: www.asccp.org/consensus2012 • Comprehensively revised management strategies • Guidelines published simultaneously in Obstetrics & • Guidance on co-testing for women 30 and older Gynecology and the Journal of Lower Genital Tract Disease • More conservative management for women 21-24 years old – Complete algorithms published in the JLGTD • Builds on past guidelines but incorporates data on risk from • 3/22/2013: A mobile app available 1.4 million women screened @ Kaiser N. California ASCCP: Important Changes Take it Home

• Women 21-24 years of age with ASC-US or LSIL can be Michael Pollan: managed either with or without a reflex HPV test Healthy eating – Preferred approach is cytology @ 12 mo; NOT REFLEX HPV Eat food – ASC-US, HPV positive: repeat cytology @ 12 mo; NOT COLPO Not too much • Endocervicals absent or insufficient, cytology negative Mostly plants – < 30 years old: routine screening in 3 years – > 30 years old: based on HPV test result • Unsatisfactory cytology: repeat in 2-4 months • LSIL with HPV negative – Repeat co-testing in 1 year preferred

Take it Home Genital Skin Rashes Michael Pollan: Healthy Cervical Cancer Healthy eating Screening Infectious Non-infectious  Eat food Start later, end sooner Candidiasis  Intertrigo  Not too much Not too often Tinea Cruris  Psoriasis Mostly plants Every 3 or 5 years  Tinea Versicolor  Atopic dermatitis (eczema)  Erythrasma What doesn’t matter for screening intervals • Age of sexual debut • Prior HPV vaccination • New sexual partners or practices • Hormonal contraceptives or hormone therapy Vulvar Candidiasis Vulvar Candidiasis • Symptoms : will be very itchy • Presentation – Often excoriated – Erythema + satellite lesions – Occasionally: thrush, LSC thickening if chronic • Diagnosis : skin scraping KOH, candidal culture • Treatment – Topical antifungal therapy daily for 7-14 days, or fluconazole 150 mg PO repeat in 3 days – Plus : TAC 0.1% or 0.5% ointment QD-BID

Tinea Cruris: “Jock Itch” • Asymmetric lesions on proximal inner thighs – Plaque rarely involves scrotum; not penile shaft • Well demarcated red plaques with accentuation of scale peripherally; no satellite lesions • Fungal folliculitis: papules, nodules or pustules within area of plaque • Treatment – Mild: topical azoles BID x10-14d, terbinafine – Severe: fluconazole 150 mg QW for 2-4 weeks – If inflammatory, add TAC 0.1% on 1 st 3 days Contact Dermatitis Contact Dermatitis

• Irritant contact dermatitis (ICD) • Common contact irritants – Elicited in most people with a high enough dose – Urine, feces, excessive sweating – Rapid onset vulvar itching (hours-days) – Saliva (receptive oral sex) • Allergic contact dermatitis (ACD) – Repetitive scratching, overwashing – Delayed hypersensitivity – Detergents, fabric softeners – 10-14 days after 1 st exposure; 1-7 d after repeat exposure – Topical corticosteroids • ICD and ACD can present with – Toilet paper dyes and perfumes – Itching, burning, swelling, redness – Hygiene pads (and liners), sprays, douches – Small vesicles or bullae more likely with ACD – Lubricants, including condoms

Contact Dermatitis Contact Dermatitis

Symmetric • Common contact allergens – Poison oak, poison ivy – Raised, Topical antibiotics, esp neomycin, bacitracin bright red, – Spermicides intense itching – Latex (condoms, diaphragms) – Vehicles of topical meds: propylene glycol – Extension to Lidocaine, benzocaine areas of irritant – Fragrances contact Contact Dermatitis: Treatment Why Not Steroid-Antifungal Combination Drugs? • Exclude contact with possible irritants • • Restore skin barrier with sitz baths, compresses Which products should be avoided? – • After hydration, apply a bland emollient Lotrisone: Clotrimazole and Betamethasone 0.5% – White petrolatum, mineral oil, olive oil – Mycolog II: Nystatin and Triamconolone acetonide • Short term mild-moderate potency steroids • Why avoid them? – TAC 0.1% BID x10-14 days (or clobetasol 0.05%) – Inflammation usually clears up before fungal infection – Fluconazole 150 mg PO weekly – Steroid overshoot  skin atrophy • Cold packs: gel packs, peas in a “zip-lock” bag – • Local immunosuppression (from steroid) may blunt Doxypin or hydroxyzine (10-75 mg PO) at 6 pm antifungal effect • If recurrent, refer for patch testing

Genital Skin Itching ISSVD 1987: Vulvar Dermatoses Type ISSVD Term Old Terms Infections Dermatoses Atrophic Lichen • Lichen sclerosus et atrophicus   Candidiasis Lichen sclerosus sclerosus • Kraurosis vulvae   Tinea cruris Lichen simplex chronicus (LSC) Hyper- Squamous cell • Hyperplastic dystrophy  • Dermatitis LS + LSC plastic hyperplasia Neurodermatitis • Lichen simplex chronicus  Psoriasis Neoplasms  Systemic Other • Lichen planus  Seborrheic dermatitis Paget’s Disease (women) dermatoses • Psoriasis   Vulvar Intraepithelial neoplasia Eczema Pre- VIN • Hyperplasic dystrophy/atypia (VIN) •  malignant Bowen’s disease Penile Intraepithelial neoplasia • Bowenoid papulosis (PIN) • Vulvar CIS ISSVD: International Society for the Study of 2006 ISSVD Classification of 2006 ISSVD Classification of Vulvar Dermatoses Vulvar Dermatoses Path pattern Clinical Corrrelates Spongiotic Atopic dermatitis, allergic contact dermatitis, • No consensus agreement on a system based upon irritant contact dermatitis clinical morphology, path physiology, or etiology Acanthotic Psoriasis, LSC (primary or superimposed), (VIN) • Include only non-Neoplastic, non-infectious entities Lichenoid Lichen sclerosus, lichen planus • Dermal Lichen sclerosus Agreed upon a microscopic morphology based system homogenization • Rationale of ISSVD Committee Vesicolobullous Pemphigoid, linear IgA disease –  Clinical diagnosis no classification needed Acantholytic Hailey-Hailey disease, Darier disease, papular – Unclear clinical diagnosis  seek biopsy diagnosis genitocrural acantholysis – Unclear biopsy diagnosis  seek clinic pathologic Granulomatous Crohn disease correlation Vasculopathic Apthous ulcers, Behcet disease, plasma c. vulvitis

The Lichens Lichen Sclerosus: Natural History

• Most common vulvar dermatosis • Prevalence: 1.7% in a general GYN practice • Cause: autoimmune condition • Bimodal age distribution: older women and children, but may be present at any age • Chronic, progressive, lifelong condition Lichen Sclerosus: Natural History Lichen Sclerosus: Findings • Symptoms • – Most commoly, itching Most common in Caucasian women – • Often irritation, burning, dyspareunia, tearing Can affect non-vulvar areas – • 58% of newly-diagnosed patients are asymptomatic Part (or all) of lesion can progress to VIN-d type • Signs • Predisposition to vulvar squamous cell carcinoma – Thin white “parchment paper” epithelium – 1-5% lifetime risk (vs. < 0.01% without LS) – Fissures, ulcers, bruises, or submucosal hemorrhage – LS in 30-40% women with vulvar squamous cancers – Changes in vulvar architecture: loss of labia minora, fusion of labia, phimosis of clitoral hood – Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus – Introital stenosis

“Early” Lichen Sclerosus Thin white epithelium Fissures Lichen Hyperpigmentation Sclerosus due to scarring

Loss of labia minora “Late” Lichen Sclerosus 68 year old woman with urinary Agglutination of obstruction clitoral hood Loss of labia Labial agglutination minora over urethral meatus Introital narrowing

Parchment paper epithelium

Lichen Sclerosus: Treatment Lichen Sclerosus: Treatment • • Biopsy mandatory for diagnosis, unless classic findings Second line therapy – • Preferred treatment Pimecrolimus, tacrolimus – – Retinoids, potassium para-aminobenzoate Clobetasol 0.05% ointment QD x4 weeks, then QOD x4 • weeks, then twice-weekly for 4 weeks Testosterone (and estrogen or progesterone) ointment or cream no longer recommended – Taper to med potency steroid (or clobetasol) 2-4 times • Explain chronicity and need for life-long treatment per month for life • – Adjunctive therapy : anti-pruritic therapy Explain “titration” regimen to patient, including – Antihistamines, especially at bedtime management of flares and recurrent symptoms – – Doxypin, at bedtime or topically 30 gm tube of ultrapotent steroid lasts 3-6 mo – If not effective: amitriptyline, desipramine PO – Monitor every 3 months twice, then annually • Perineoplasty may help dyspareunia, fissuring Lichen Simplex Chronicus = Lichen Simplex Chronicus Squamous Cell Hyperplasia

• Cause: an irritant initiates a “scratch-itch” cycle • LSC classified as – Primary (idiopathic) – Secondary (superimposed upon lichen sclerosus, candida vulvitis; vulvar contact dermatitis) • Presentation : always itching ; burning, pain, tenderness • Signs : Thickened red (white if moisture) raised lesion • In absence of atypia, no malignant potential – If atypia present , classified as VIN

L. Simplex Chronicus: Treatment Lichen Sclerosus + LSC • • Removal of irritants or allergens “Mixed dystrophy” deleted in 1987 ISSVD System • Treatment • – Triamcinolone ac etonide (TAC) 0.1% ointment BID x4- 15% all vulvar dermatoses 6 weeks, then QD • LS is irritant; scratching  LSC – Other moderate strength steroid ointments • Consider: LS with plaque, VIN, – Intralesional TAC once every 3-6 months squamous cell cancer of vulva • Anti-pruritics • Treatment – Hydroxyzine (Atarax) 25-75 mg QHS – – Clobetasol x12 weeks, then Doxepin 25-75 mg PO QHS steroid maintenance – Doxepin (Zonalon) 5% cream; start QD, work up – Stop the itch!! Vulvar Intraepithelial Neoplasia (VIN): ISSVD Classification of VIN Prior to 2004 (2004) • Grading of VIN-1 through VIN-3, based upon degree of • Since VIN 1 is not a cancer precursor, abandon use of term epithelial involvement – Instead, use “condyloma” or “flat wart” • The mnemonic of the 4 P’s • Combine VIN-2 and VIN-3 into single “VIN” diagnosis – Papule formation: raised lesion (erosion also • Two distinct variants of VIN possible, but much less common) – ISSVD 1986 ISSVD 2004 Pruritic : itching is prominent VIN-u – VIN 1 Flat condyloma “Patriotic ”: red, white, or blue (hyperpigmented) VIN 2 VIN-usual (VIN-u) Warty – Parakeratosis on microscopy VIN 3 VIN-usual (VIN-u) Basaloid Differentiated VIN-differentiated (VIN-d) Mixed

ISSVD: VIN, Usual Type (VIN-u) White VIN, Usual (warty) type • Usually HPV-related (mainly type 16) • More common in younger women (30s-40s) • Often asymptomatic • Lesions usually elevated and have a rough surface, although flat lesions can be seen • Often multifocal (incl periurethral and perianal areas) and multicentric in 50% • Strongly associated with immunocompromise, smoking • Low malignant potential (5-20%) – Progression more likely with the basaloid type VIN, usual (basaloid) type

VIN-d: Differentiated Type

• Usually in older women with LS, LSC, or LP • VIN: Not HPV related • warty- Far less common than VIN-usual type • basaloid Symptoms : long history of pruritus and burning • type Findings – Red, pink, or white papule; rough or eroded surfaces – A persistent, non-healing ulcer – Unifocal, unicentric • More likely to progress to SCC of vulva than VIN-u (90%) Vulvar Intraepithelial Neoplasia Genital Skin: Dark Lesions (% are in women only) • Risk of invasion: greater if immunocompromised (steroids, HIV), >40 years old, previous lower genital tract neoplasia • • 36% Lentigo, benign genital melanosis Treatment • – Wide local excision: highest cure rate, esp hair-bearing 22% VIN • – CO 2 laser ablation: best cosmetic result 21% Nevi (mole) • – Topical agents: imiquimod 10% Reactive hyperpigmentation (scarring) • – Skinning or simple vulvectomy rarely used 5% Seborrheic keratosis • Recurrence is common (48% at 15 years) • 2% Malignant melanoma – Monitor @ 6,12 months, then annually • 1% Basal cell or squamous cell carcinoma – Smoking cessation may reduce recurrence rate • Prevention : HPV-4 vaccin e

Vulvar Intraepithelial Neoplasia

Hyperpigmented VIN, usual type Lichen Sclerosus with Scarring Vulvar Melanoma: ABCDE Rule

A: Asymmetry B: Border Irregularities C: Color black or multicolored D: Diameter larger than 6 mm E: Evolution – Any change in mole should arouse suspicion – Biopsy mandatory when melanoma is a possibility

Atypical Early Nodular Metastatic Nevus Melanoma Melanoma Melanoma Indications for Vulvar Biopsy Cervical Cancer Screening: References

• Papular or exophtic lesions, except obvious condylomata • Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin • Thickened lesions (biopsy thickest region) to differentiate Number 131: Screening for cervical cancer. Obstet Gynecol. 2012 Nov;120(5):1222-38 VIN vs. LSC • • CDC. Cervical cancer screening among women aged 18-30 years - Hyperpigmented lesions (biopsy darkest area), unless United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2013 Jan obvious nevus or lentigo 4;61:1038-42 • Ulcerative lesions (biopsy at edge), unless obvious herpes, • Saslow D, American Cancer Society, American Society for Colposcopy syphilis or chancroid and Cervical Pathology, and American Society for Clinical Pathology • screening guidelines for the prevention and early detection of cervical Lesions that do not respond or worsen during treatment cancer. Am J Clin Pathol. 2012 Apr;137(4):516-42. • In summary : biopsy whenever diagnosis is uncertain • Moyer VA; Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jun 19;156(12):880-91

Vulvar Skin: References Vulvar Skin: References • • Lynch PJ, et.al. 2011 ISSVD Terminology and Classification of Heller DS. Report of a new ISSVD classification of VIN. J Low Vulvar Dermatological Disorders: An Approach to Clinical Genit Tract Dis. 2007 Jan;11(1):46-7. • Diagnosis . J Low Genit Tract Dis. 2012 Oct;16(4):339-44 Siderite M, et al. Squamous vulvar intraepithelial neoplasia: • Lynch PJ, etal, 2006 ISSVD Classification of Vulvar Dermatoses. 2004 modified terminology, ISSVD Vulvar Oncology J Reprod Med 2007;52:3-9 Subcommittee J Reprod Med. 2005 Nov;50(11):807-10 • • ACOG Practice Bulletin #93. Diagnosis and Management of Wechter ME, Management of Bartholin duct cysts and Vulvar Skin Disorders. Ob Gynecol 2008;111 (5);1243-1253 abscesses: a systematic review Obstet Gynecol Surv. 2009 • Jun;64(6):395-404. Smith YR, Haefner HK. Vulvar lichen sclerosus: • pathophysiology and treatment. Am J Clin Dermatol. vanSeters, et al, Treatment of vulvar intraepithelial neoplasia 2004;5(2):105-25. with imiquimod. NEJM 2008;358:1465-73 • • Foster DC, Vulvar disease. Ob Gynecol. 2002;100(1):145-63. De Simone P Vulvar melanoma: a report of 10 cases and review of literature. Melanoma Res. 2008 Apr;18(2):127-33