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Dr. Stewart is the author (with Paula Spencer) of the bestselling book, The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, OBGMANAGEMENT New York: Bantam Books; 2002

Vulvovaginal disorders: 4 challenging conditions How to identify and treat , contact , , and vestibulodynia

he symptoms are recited every day in mislead the clinician into thinking appropri- gynecologists’ offices around the ate therapy “doesn’t work.” And it is impor- world: itching, irritation, burning, tant to remember that any genital complaint Elizabeth G. Stewart, MD T Director, Vulvovaginal Service, rawness, pain, . The challenge has the potential to dampen a woman’s self- Harvard Vanguard Medical is tracing these general symptoms to a spe- esteem and hamper sexual function. Associates, and Assistant Professor cific pathology, a task harder than one This article covers the fine points of of Obstetrics and Gynecology, ® Dowden Health Media Harvard Medical School, Boston might expect, because vulvovaginal condi- diagnosis and treatment of 4 common vul- tions often represent a complex mix of sev- vovaginal problems: eral problems. Candida andCopyright bacterial inva-For personal1. Candidiasis use only sion frequently complicate genital 2. Contact dermatitis dermatologic conditions. Atrophy and loss 3. Lichen sclerosus of the epithelial barrier worsen the problem. 4. Vestibulodynia Over-the-counter (OTC) and prescription Could all 4 problems coexist in 1 IN THIS ARTICLE remedies can lead to contact dermatitis. patient? They frequently do. As always, a may be the ultimate outcome, careful history and physical examination ❙ 9 essential steps possibly from central sensitization after with appropriate use of yeast cultures make for treatment chronic inflammation, which in turn can it possible to manage the complexity. of contact dermatitis Page 37 1. CANDIDIASIS ❙ Telephone and self-diagnosis are a waste of time Lichen sclerosus: Why lifelong follow-up n vulvovaginal candidiasis (VVC), parapsilosis, krusei, lusitaniae, and tropi- is a must Isymptoms can range from none to calis are more difficult to treat. Page 38 recurrent. VVC can complicate genital dermatologic conditions and interfere Not all episodes are the same ❙ Tricyclic with the treatment of illnesses that call VVC is uncomplicated when it occurs spo- antidepressants for or antibiotics. Because the radically or infrequently in a woman in good symptoms of VVC are nonspecific, diag- overall health and involves mild to moderate for persistent pain nosis necessitates consideration of a long symptoms; albicans species are likely. VVC Page 46 list of other potential causes, both infec- is complicated when it is severe or recurrent tious and noninfectious. or occurs in a debilitated, unhealthy, or preg- Candida albicans predominates in 85% to nant woman; non-albicans species often are 90% of positive vaginal yeast cultures. involved. Proper classification is essential to Non-albicans species such as C glabrata, successful treatment.1

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▲ Vulvovaginal disorders: 4 challenging conditions

Phone diagnosis TABLE 1 is usually inaccurate CDC guidelines Although phone diagnosis for treatment of candidiasis is unreliable,2 it is still fair- Any of these intravaginal or oral ly common, and fewer regimens may be used offices use microscopy and DOSE vaginal pH to diagnose (NUMBER OF DAYS) vaginal infections because INTRAVAGINAL AGENTS of the tightened (though still Butoconazole simple) requirements of the 2% cream* 5 g (3) Clinical Laboratory Improve- Butoconazole-1 ment Amendment. (Clinicians sustained-release cream 5 g (1) who do wet mounts and KOH are Clotrimazole required to pass a simple test each year 1% cream* 5 g (7–14) to continue the practice.) 100 mg 1 tablet (7) Women are poor self-diagnosticians when it comes to Candida infection; only one third 2 tablets (3) of a group purchasing OTC antifungals 500 mg 1 tablet (1) had accurately identified their condition.3 Miconazole Clinicians are not exempt from error, either. 2% cream* 5 g (7) About 50% of the time, Candida is mis- 100 mg* 1 suppository (7) 4 diagnosed, largely because of the 200 mg* 1 suppository (3) assumption that the wet mount is more Nystatin specific than it actually is (it is only 40% 100,000 U 1 tablet (14) specific for Candida). Tioconazole Ask about sex habits, douching, 6.5% ointment* 5 g (1) drugs, and diseases Terconazole FAST TRACK Accurate diagnosis requires a careful his- 0.4% cream 5 g (7) The wet mount tory, focusing on risk factors for 0.8% cream 5 g (3) Candida: a new sexual partner; oral sex; 80 mg 1 suppository (3) is only 40% douching; use of antibiotics, steroids, or ORAL AGENT specific for Candida exogenous ; and uncontrolled Fluconazole diabetes. Look for signs of vulvar and vaginal 150 mg 1 tablet (1) erythema, edema, and excoriation. * Over-the-counter Classic “cottage cheese” discharge may not be present, and the amount has no cor- Azole antifungals are usual treatment relation with symptom severity. For uncomplicated VVC, azole antifungals Vaginal pH of less than 4.5 excludes bacter- are best (TABLE 1). For complicated VVC, ial vaginosis, trichomoniasis, atrophic follow this therapy with maintenance flu- , desquamative inflammatory conazole (150 mg weekly for 6 months), vaginitis, and vaginal . which clears Candida in 90.8% of cases.5 Blastospores or pseudohyphae are diagnostic Non-albicans infection can be treated with

(on 10% KOH microscopy). If they are boric acid capsules (inserted vaginally at IMAGE: absent, a yeast culture is essential and will bedtime for 14 days) or terconazole cream (7 allow speciation. A vaginal culture is espe- days) or suppositories (3 days). A culture to KIMBERLY cially important in women with recurrent or confirm cure is essential, since non-albicans

refractory symptoms. infection can be difficult to eradicate. MARTENS Always consider testing for sexually trans- Note that boric acid is not approved for mitted diseases. pregnancy.

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2. CONTACT DERMATITIS Nine essentials of treatment

ontact dermatitis, the most common and edema; scaling is possible. Severe Cform of vulvar dermatitis, is inflam- cases manifest as erosion, ulceration, or mation of the skin caused by an external pigment changes. Secondary infection, if agent that acts as an irritant or allergen. any, may involve pustules, crusting, and The skin reaction may escape notice fissuring. The dermatitis may be local- because changes ranging from minor to ized, but often extends over the area of extreme are often superimposed on com- product spread to the mons, labiocrural plex preexisting conditions such as lichen folds, and anus. C albicans often compli- simplex chronicus, lichen planus, and cates genital dermatologic conditions. lichen sclerosus.6 Contact dermatitis occurs readily in 9-step treatment the vulvar area because the skin of the 1. Stop the offending product and/or reacts more intensely to irritants practices. than other skin, and its barrier function 2. Restore the skin barrier with sitz baths COMMON VULVAR is easily weakened by moisture, friction, in plain lukewarm water for 5 to 10 IRRITANTS urine, and . The 3 main minutes twice daily. Compresses or a CAUSTIC AGENTS types of irritant dermatitis are7: handheld shower are alternatives. Bichloracetic acid • A potent irritant, which may produce 3. Provide moisture. After hydration, Trichloroacetic acid the equivalent of a chemical burn. have the patient pat dry and apply a 5-Fluorouracil • A weaker irritant, which may be thin film of plain petrolatum. Lye (in soap) applied repeatedly before inflamma- 4. Replace local estrogen if necessary. Phenol Podophyllin tion manifests. 5. Control any concomitant Candida Sodium hypochlorite • Stinging and burning, which can occur with oral fluconazole 150 mg weekly, Solvents without detectable skin change, avoiding the potential irritation caused WEAK CUMULATIVE due to chemical exposure. by topical antifungals. IRRITANTS Many products can cause dermatitis. 6. Treat itching and scratching with Alcohol Even typically harmless products can cause cool gel packs from the refrigerator, Deodorants Diapers dermatitis if combined with lack of estro- not the freezer (frozen packs can Feces gen or use of pads, panty hose, or girdles. burn). Stop involuntary nighttime Feminine spray scratching with sedation: doxepin or Pads Perfume No typical pattern hydroxyzine (10–75 mg at 6 PM). Povidone iodine Patients complain of varying degrees of itch- 7. Use topical steroids for dermatitis: Powders ing, burning, and irritation. Depending on • Moderate: Triamcinolone, 0.1% Propylene glycol the agent involved, onset may be sudden or ointment twice daily. Semen gradual, and the woman may be aware or • Severe: A super-potent such Soap Sweat oblivious of the cause. New reactions to as clobetasol, 0.05% ointment, Urine “old” practices or products are also possible. twice daily for 1 to 3 weeks. Vaginal secretions Ask about personal hygiene, care during • Extreme: Burst and taper pred- Water menses and after intercourse, and about nisone (0.5–1 mg/kg/day decreased Wipes soap, cleansers, and any product applied to over 14–21 days) or a single dose of PHYSICALLY ABRASIVE the genital skin, as well as clothing types intramuscular triamcinolone CONTACTANTS Face cloths and exercise habits. Review prescription (1 mg/kg). Sponges and OTC products, including topicals, and 8. Order patch testing to rule out or THERMAL IRRITANTS note which products or actions improve or define allergens. Hot water bottles aggravate symptoms. A history of allergy 9. Educate the patient about the many Hair dryers and atopy should heighten suspicion. potential causes of dermatitis, to pre- Source: Lynette Margesson, MD26 The physical exam may reveal erythema vent recurrence.

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A mutilating disease of mysterious origin

A B

Though lichen sclerosus is a disfiguring disease, the intensity of symptoms does not necessarily correlate with clinical appearance. Generally, the first change is (A) whitening of an irregular area on the labia, near the , on the perineum, and/or other vulvar areas. In some cases (A and B), inflammation can alter the anatomy of the vulva by flattening the labia minora, fusing the hood over the clitoris, effectively burying it beneath the skin, and shrinking the skin around the vaginal opening. Images courtesy Lynette Margesson, MD

3. LICHEN SCLEROSUS Lifelong follow-up is a must

lthough it has long been described in Affects 1.7%, or 1 in 60 women.12 In females, Amedical journals and textbooks, infor- lichen sclerosus peaks in 2 populations: mation on lichen sclerosus was often unre- prepubertal girls and postmenopausal liable until recently, and adequate treat- women. FAST TRACK ment guidelines were lacking. The cause No remission after age 70. Although remis- Teach the patient still has not been fully elucidated, but a sion of the disease has been reported, a wealth of information now allows for con- recent study concluded that lichen sclero- self-examination, siderable expertise in the management of sus never remits after the age of 70; the because carcinoma this disease. average length of remission is 4.7 years, can arise quickly, Lichen sclerosus is a chronic inflam- although this figure is still in question.13 between annual matory and scarring disease that preferen- Only close follow-up can determine if dis- tially affects the anogenital area and is 6 to ease is in remission. or semi-annual 10 times more prevalent in women than follow-up visits men.8 Any cutaneous site may also be Main symptom is itching affected, but the is never involved. Pruritus is the most common symptom, but Infection? Autoimmunity? An infectious dysuria and a sore or burning sensation cause has been proposed but never proven. have also been reported. Some women have In some women, an autoimmune compo- no symptoms. When erosions, fissures, or nent is recognized: Immunoglobulin G anti- introital narrowing are present, dyspareu- bodies to extracellular matrix protein I have nia may also occur. been found in 67% of patients with lichen Typical lesions are porcelain-white papules sclerosus, but whether these antibodies are and plaques, often with areas of fissuring secondary or pathogenic is unclear.9 A genet- or ecchymosis on the vulva or extending ic component is suggested by the association around the anus in a figure-of-8 pattern. with autoimmunity and by the link with Both lichen sclerosus and lichen planus human leukocyte antigen DQ7 in women10 may be seen on the same vulva. and girls.11 Squamous cell carcinoma can arise in

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INTEGRATING EVIDENCE AND EXPERIENCE

Ultrapotent steroids: Good control, but risk of malignancy persists

Renaud-Vilmer C, Cavalier-Balloy B, Porcher in younger women is only temporary, and steroid R, Dubertret L. Vulvar lichen sclerosus. Arch therapy offers no significant reduction in the risk of Dermatol. 2004;140:709–712. —although carcinoma developed only in untreated or irregularly treated lesions. f we gynecologists have been assuming that Histologic and clinical findings were used to lichen sclerosus is one of those nebulous, little- judge efficacy. Because only 83 women were stud- Iexplored diseases out there, we need to think ied, the cohort is too small for the findings on carci- again. Lichen sclerosus is a chronic and mutilating noma to be significant, but the authors emphasized condition, an obstacle to quality of life, a threat to that lifelong follow-up is necessary in all cases. body image, a destroyer of sexual function, and a risk for malignancy. Lichen sclerosus never backs down after menopause Cancer developed only in untreated In more than 15 years of vulvovaginal specialization, or irregularly treated lesions I have found similar results. Older women detest the In a key study, Renaud-Vilmer and colleagues13 need to apply topicals to the genital area, but they explored remission and recurrence rates after are the ones who need ongoing use, because the treatment with 0.05% clobetasol propionate oint- disease never backs down after menopause. ment, as well as whether the treatment reduces risk I follow a cohort of young women in whom I of malignant evolution. They determined that the rate detected early disease. Their clinical signs regressed of clinical and histologic remission is related to age. and scarring was prevented by steroid treatment, Although 72% of women under age 50 had complete but disease recurrence appears to be inevitable: remission, only 23% of women between 50 and 70 The longest remission has been just over 4 years. years of age had complete remission, and none of I have seen cancer arise quickly even in closely the women older than 70 did. Relapse was noted in supervised patients, although many cases of squa- most women over time (50% by 18 months), and mous cell carcinoma have occurred in women with 9.6% of women were later diagnosed with invasive undetected or poorly treated disease. squamous cell carcinoma. Although we have known since 1988 that ultra- Use tacrolimus with caution potent steroids offer outstanding relief of symptoms Although small trials have produced some enthusi- and some control over the disease, the optimal length asm for therapeutic use of tacrolimus, treatment of treatment has never been clear. The prospective should proceed with extreme caution, as the drug study by Renaud-Vilmer et al has impressive power inhibits an arm of the immune system and women that derives from its 20-year duration. They demon- with lichen sclerosus are at risk for malignancy. The strated that ultrapotent steroids do not cure lichen agent now carries a warning based on the develop- sclerosus in women over 70. Complete remission ment of malignancy in animals.

anogenital lichen sclerosus; risk is thought diagnosis, treatment should be consid- to be 5%. Instruct women in regular self- ered even in the face of an inconclusive examination because carcinoma can arise or negative finding if the clinician sus- between annual or semiannual visits. pects that lichen sclerosus is present. The reason treatment should proceed in these Consider treatment cases: Loss of the labia or fusion over the even without biopsy proof clitoris can occur if the disease progress- Although a biopsy generally makes the es, as shown in the photos on page 38.

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Powerful corticosteroids her to discontinue treatment but follow her are treatment of choice every 3 to 6 months. Treatment can control lichen sclerosus, Treatment also requires educating relieve symptoms, and prevent further the patient about the disease, instructing anatomical changes. Potent or ultrapotent her in gentle local care, and showing her topical corticosteroids in an ointment base exactly where to apply the ointment. are preferred. These drugs are now widely In all cases, lifelong follow-up is neces- recognized for their efficacy and minimal sary. Hyperkeratosis, ecchymoses, fissur- adverse effects, although no regimen is uni- ing, and erosions resolve, but atrophy and versally advocated.14 The patient applies color change remain. Scarring usually ointment once daily for 1 to 3 months, remains unchanged, but may resolve if depending on severity, and then once or treated early in the course of the disease.15 twice a week. Testosterone is not as effective as an Ointments are preferred over creams ultrapotent steroid,16 and is no more effec- for vulvar treatment, because creams fre- tive than an emollient.17 quently contain allergens or irritants Estrogen is valuable for skin integrity, such as fragrance and propylene glycol but has no role in the treatment of lichen preservative. sclerosus. I continue once-weekly therapy indefinitely Dilator work may be necessary for dyspare- in postmenopausal women. If a pre- unia, once the disease is controlled. menopausal woman is not comfortable Refer for help with depression and/or nega- using the ointment indefinitely, I will allow tive body image, if present.

4. VESTIBULODYNIA Eight treatment options to try he prevalence of pain in an ethnically and it is secondary if it arises after a period Tdiverse population is 16%, and of comfortable sexual function. FAST TRACK approximately half of this figure (8%) rep- Vestibulodynia resents vulvodynia.18 The International Inflammation starts the cascade Society for the Study of Vulvovaginal Current theory suggests that inflammato- is the leading cause Disease now classifies vulvar pain in 3 cat- ry events such as yeast infection, seminal of dyspareunia egories: plasma allergy, and local chemical appli- in women under 50 • vulvar pain with a known cause, includ- cation release a cascade of cytokines that ing infection, trauma, and systemic dis- sensitizes nociceptors in the vestibular ease (TABLE 2), epithelium. Prolonged neural firing in turn • generalized vulvodynia, also known as alters neurons in the dorsal horn, allowing dysesthetic vulvodynia, essential vulvo- sensitization of mechanoreceptive fibers in dynia, or pudendal , and the vestibule with sensory allodynia (pain • localized vulvodynia or vestibulodynia, on touch). The proliferation of introital formerly called vestibulitis, vulvar nociceptive fibers is well documented.20 vestibulitis syndrome, and vestibular adenitis. Diagnosis: Report of pain Terminology is likely to evolve with and a positive Q-tip test further study. When a woman reports superficial dys- Vestibulodynia, the leading cause of pareunia with introital contact and clinical dyspareunia in women under age 50,19 examination reveals pain on touch in the refers to pain on touch within the vestibule. vestibule (using a cotton swab), vestibulo- It is primary pain if it has been present since dynia is diagnosed, provided no other the first use or sexual experience, known causes of the vulvar pain are detect-

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TABLE 2 prior sexual issues, and the impact of the Rule out these known causes current with an eye of vulvar pain toward guiding support and counseling.

INFECTIONS Multifactorial treatment: 8 options • Bartholin abscess Because the cause of vestibulodynia is • Candida albicans unclear, a multifactorial approach general- • Herpes ly is accepted and involves the following: • Molluscum 1. Patient education about the problem • Trichomonas and instruction in gentle local care and TRAUMA the elimination of contactants. 2. Referral for support, counseling, and • Sexual assault treatment of depression, as indicated. • Other physical injury 3. Elimination of any known trigger such SYSTEMIC DISEASE as C albicans, although this generally • Behçet disease does not lead to remission unless the • Crohn disease pain is also treated. • Sjögren syndrome 4. Suppression of nociceptor afferent • Systemic input using topical CANCER AND PRE-CANCER hydrochloride, for which good results have been reported.21 • Vulvar cancer 5. Systemic oral analgesia with a tricyclic • Vulvar intraepithelial neoplasia (VIN) antidepressant modulates the sero- IRRITANTS tonin and epinephrine imbalance asso- • Soaps ciated with persistent pain (TABLE 3).22 • Sprays 6. Use of anticonvulsants such as • Douches gabapentin to increase the amount of • Topical anesthetics stimuli needed for nerves to fire and 23 FAST TRACK • Antiseptics elevate the central pain threshold. 7. Reduction of muscle tension and As a last resort • Suppositories spasm in the pelvic floor, using physi- for vestibulodynia, • Creams cal therapy and .24 • HPV treatment 8. When medical management fails, vul- with vaginal • 5-FU var vestibulectomy with vaginal advancement • Laser treatment advancement yields excellent long-term results,25 but should be a last resort. ■ yields excellent SKIN CONDITIONS • Allergic or contact dermatitis REFERENCES long-term results • Eczema 1. Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidi- asis: epidemiologic, diagnostic, and therapeutic consid- • Psoriasis erations. Am J Obstet Gynecol. 1998;178:203–211. • Hidradenitis suppurativa 2. Spinollo A, Pizzoli G, Colonna L, Nicola S, DeSeta F, Guashino S. Epidemiologic characteristics of women • Lichen planus with idiopathic recurrent vulvovaginal candidiasis. Obstet Gynecol. 1999;180:14–17. • Lichen sclerosus 3. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, • Pemphigoid and pemphigus Litaker MS. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal can- 27 Source: Haefner and Pearlman didiasis. Obstet Gynecol. 2002;99:419–425. 4. Ledger WJ, Polaneczky MM, Yih MC. Difficulties in the ed during a careful history and examina- diagnosis of Candida vaginitis. Inf Dis Clin Pract. 2000;9:66–69. tion or after pH measurement, a wet 5. Sobel JD, Wiesenfeld HC, Martens M, et al. mount, and any indicated cultures. Maintenance fluconazole therapy for recurrent vulvo- vaginal candidiasis. N Engl J Med. 2004;35:876–883. A careful psychosexual history can help the 6. Margesson LJ. Contact dermatitis of the vulva. clinician identify current sexual practices, Dermatol Ther. 2004;17:20–27.

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TABLE 3 Tricyclic antidepressants modify chemical imbalance associated with persistent pain of vestibulodynia

Names of standard Amitriptyline (Elavil) agents used Nortriptyline (Aventyl, Pamelor) Desipramine (Norpramin) Imipramine (Tofranil) Standard dosing Start with 10 mg; increase by 10 mg weekly to 100–150 mg Side effects Sedation, often transient Constipation, must be actively managed Dry mouth Palpitations, tachycardia Sun sensitivity Cautions Obtain EKG over 50 years or with cardiac history Contraindicated in glaucoma Levels must be monitored if combined with SSRI Success Slow change over 6–12 months in sensitivity to touch; ability to use tampon. Minimal pain with dilator use, penetration Failure Over 3 months at max dose without any improvement

7. Kamarashev JA, Vassileva SG. Dermatologic diseases 19. Meana M, Binik YM, Khalife S, et al. Biopsychosocial of the vulva. Clin Dermatol. 1997;15:53–65. profile of women with dyspareunia. Obstet Gynecol. 8. Powell J, Wojnarowska F. Lichen sclerosus. Lancet. 1997;90:583–589. 1999;353:1777–1783. 20. Bohm-Starke N, Hilliges M, Falconer C, Rylander E. 9. Oyama N, Chan I, Neill SM, et al. Autoantibodies to Neurochemical characterization of the vestibular extracellular matrix protein 1 in lichen sclerosus. nerves in women with syndrome. Lancet. 2003;362:118–213. Gynecol Obstet Invest. 1999;48:270–275. 10. Marren P, Yell J. Charnock FM, Bunce M, Welsh K, FAST TRACK Wojnarowska F. The association between lichen sclero- 21. Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% sus and antigens of the HLA system. Br J Dermatol. lidocaine ointment for treatment of vulvar vestibulitis. Start a tricyclic 1995;132:197–203. Obstet Gynecol. 2003;102:84–87. 11. Powell J, Wojnarowska F, Winsey S, Marren P, Welsh K. 22. Mariani L. Vulvar vestibulitis syndrome: an overview of antidepressant Lichen sclerosus premenarche: autoimmunity and immunogenetics. Br J Dermatol. 2000;142:481–484. nonsurgical treatment. Eur J Obstet Gynecol. at a dose of 10 mg 2002;101:109–112. 12. Goldstein AT, Marinoff SC, Cristopher K, Srodon M. daily, increasing Prevalence of vulvar lichen sclerosus in a general 23. Graziottin A, Vincenti E. Analgesic treatment of gynecology practice. J Reprod Med. 2005;50:477–480. intractable pain due to vulvar vestibulitis syndrome: by 10 mg per week 13. Renaud-Vilmer C, Cavalier-Balloy B, Porcher R, preliminary results with oral gabapentin and anesthet- Dubertret L. Vulvar lichen sclerosus. Arch Dermatol. ic block of ganglion impar. Poster presented at: until the total dose 2004;140:709–712. International Meeting of the International Society for is 100–150 mg 14. Dalziel KL, Millard PR, Wojnarowska F. The treatment the Study of Women’s Sexual Health; 2002; Vancouver, of vulval lichen sclerosus with a very potent topical Canada. steroid (clobetasol propionate 0.05%) cream. Br J Dermatol. 1991;124:461–464. 24. Glazer HI, Rodke G, Swencionis C, Hertz R, Young AW. 15. Cooper SM, Gao XH, Powell JJ, Wojnarowska F. Does Treatment of vulvar vestibulitis syndrome with elec- treatment of vulvar lichen sclerosus influence its prog- tromyographic biofeedback of pelvic floor muscula- nosis? Arch Dermatol. 2004;140:702–706. ture. J Reprod Med. 1995;40:283–290. 16. Bornstein J, Heifetz S, Kellner Y, et al. Clobetasol dipro- 25. Haefner HK, Collins ME, Davis GD, et al. The vulvody- pionate 0.05% versus 2% testosterone application for nia guideline. J Lower Gen Tract Dis. 2005;9:40–45. severe vulvar lichen sclerosus. Am J Obstet Gynecol. 1998;178:80–84. 26. Margesson LJ. Inflammatory disorders of the vulva. In: 17. Sideri M, Origoni M, Spinaci L, Ferrari A. Topical Fisher BK, Margesson LJ, eds. Genital Skin Disorders testosterone in the treatment of vulvar lichen sclero- Diagnosis and Treatment. St Louis: Mosby; 1998:155–157. sus. Int J Gynecol Obstet. 1994;46:53–56. 27. Haefner HK, Pearlman MD. Diagnosing and managing 18. Harlow BL, Stewart EG. A population-based assess- vulvodynia. Contemp ObGyn. 1999;2:110. ment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58:82–88. The author reports no financial relationships relevant to this article.

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