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December 1, 2008 • www.familypracticenews.com Women’s Health 27 Avoid Empiric Treatment for Vulvar Disorders

BY NANCY WALSH vulva and anus. Hypopigmentation also is characteristic, ment once daily after soaking. “I believe the Temovate New York Bureau with scarring and architectural changes including phimo- brand is much better than the generic, probably because sis of the clitoris, resorption of the labia minora, and nar- of the vehicle,” he said. The corticosteroid should be con- L AKE B UENA V ISTA, FLA. — Empiric treatment rowing of the introitus causing recurrent tearing. It prob- tinued until active disease has resolved, not just for the 2 with corticosteroids should be avoided in patients who pre- ably is autoimmune, because patients have a high incidence weeks specified in the package insert. sent with vulvar symptoms such as burning, itching, pain, of other autoimmune diseases, especially thyroid disease. A second vulvar condition, , and dyspareunia, according to Dr. Andrew T. Goldstein. can develop at any age, including is characterized by thick, lichenified skin of the labia ma- These patients should have a careful examination of the childhood, and is more common than generally appreci- jora and interlabial sulcus, accompanied by erosions, fis- vulva using a colposcope, and if a lesion is present, a 4- ated, with a prevalence of 1 in 70 women. But “you have suring, and tears in the skin that result from the patient’s mm punch biopsy is warranted. to look for it. The vulva is not just something to separate scratching in her sleep, said Dr. Goldstein. This condition When the biopsy specimen is sent to the der- with a speculum when you do a Pap smear. It has been represents the end stage of mast- and histamine-me- matopathologist, it’s important to provide clinical corre- termed the forgotten pelvic organ.” diated -scratch-itch cycle in predisposed patients that lates and a differential diagnosis or the result is likely to Punch biopsy performed before initiating treatment can be initiated by irritants, allergens, or infections. be simply descriptive rather than diagnostic, said Dr. may show of the , epidermal at- All irritants must be stopped, including soaps, deter- Goldstein, who is in group practice in Washington. rophy with loss of rete ridges, homogenization of the col- gents, and , and underwear must be washed by Patients should know the full name of their disorder, lagen in the upper , and a lichenoid inflammato- in plain hot water. Daily warm-water sitz baths whether lichen sclerosus, lichen simplex chronicus, or ero- ry infiltrate in the dermis. Identifying this condition is should be followed by the application of a high-potency sive , Dr. Goldstein said at the annual meet- critical, as patients with lichen sclerosus have a relative topical corticosteroid, which must be rubbed into the skin ing of the International Pelvic Pain Society. risk of 300 for developing squamous cell carcinoma of the for 3-4 minutes. Breaking the nocturnal itch-scratch cy- Lichen sclerosus presents with itching, burning, dys- vulva, said Dr. Goldstein, also of George Washington Uni- cle can be accomplished by bedtime amitriptyline, 10-50 pareunia, and skin texture changes often described as “cig- versity Hospital, Washington. mg, and the application of a bag of frozen peas to the vul- arette paper” skin, with crinkling and fissures around the Treatment of lichen sclerosus is clobetasol 0.05% oint- var area during the night. ■ As Menarche Starts Earlier, Expert Think Behçet’s When Reviews ‘Normal’ Cycles in Teens Aphthous Ulcers Recur

BY SHERRY BOSCHERT girls), said Dr. Hillard, who did not have similar BY NANCY WALSH into the forearm, has a very high San Francisco Bureau data for African American girls. New York Bureau predictive value, although its An evaluation would be appropriate if a girl has negative predictive value is less. S TANFORD, CALIF. — A teenage patient com- no menses by age 15 years. An evaluation also is LAKE BUENA VISTA, FLA. — If induration develops 24-48 plains of “heavy” menstrual periods. Her moth- warranted if there’s no breast development by age The diagnosis of Behçet’s dis- hours later at the site of needle er mentions that her daughter never gets periods 13 years, if menses haven’t started 2.5-3 years af- ease must be considered in any insertion, the test is positive, he during soccer season. ter breast development, if there are signs or symp- patient with recurrent oral and said at the annual meeting of the Should you evaluate the girl for abnormal uter- toms of pregnancy, or if the patient is 14 years old vulvar aphthous ulcers, even if International Pelvic Pain Society. ine bleeding? with obesity, , and hirsutism. the deep, full-thickness ulcers in Although a positive pathergy Test your knowledge of what’s normal or ab- Consider polycystic ovarian syndrome (PCOS), the mouth and vulva develop at test is helpful in the diagnosis of normal for teenage menstruation by taking the anorexia nervosa, or other eating disorders as pos- different times. Behçet’s disease, only a minority true or false quiz (see box) before reading com- sible causes. If the mother says her daughter nev- Behçet’s disease is a chronic of Behçet’s patients demonstrate mentary provided by Dr. Paula J. Hillard at a pe- er gets periods during soccer season, “this may be inflammatory most the pathergy phenomenon, ac- diatric update sponsored by Stanford University. cause for concern,” Dr. Hillard said. commonly seen along the an- cording to the Vasculitis Founda- Puberty and menarche generally arrive several Early menstrual cycles in a girl’s life may be cient silk route from Japan and tion. Patients from the Mediter- months earlier for African American girls than for anovulatory and shorter or longer than some across Korea, Turkey, and ranean region are more likely to white girls, studies in the past decade have shown. others; they should not be chaotically irregular. Greece, according to Dr. An- show a positive response, with While only 7% of white girls had “early” breast Most cycles average 21-45 days in the first gyne- drew T. Goldstein. In the west it only 50% of patients in Middle development or pubic by age 7 years, this oc- cologic year and trend toward shorter, more regu- occurs most often among young Eastern countries and Japan curred in 27% of African American girls, one lar cycles with age. A 90-day cycle still falls within women of Asian or Mediter- showing the reaction. A positive study found (Pediatrics 1997;99:505-12). the 95th percentile during the first year of menar- ranean descent. reaction is even less common in Guidelines suggest not evaluating for preco- che. Beyond 90 days, evaluate for PCOS, eating dis- “This is a bad vasculitis, with the United States, and other con- cious puberty unless breast development or pubic orders, thyroid disease, hyperprolactinemia, go- complications including dissec- ditions can occasionally mimic hair occurs before age 7 years in white girls or be- nadal dysgenesis, or premature ovarian failure. ■ tion of the aorta, blindness, and the results ( www.vasculitisfoun- fore age 6 years in African American girls. If stroke,” he said. dation.org/pathergytest). there are other signs or symptoms such as severe Aside from the aphthous ul- Treatments that have been headache or neurologic symptoms, however, an The True or False cers, patients with Behçet’s dis- tried for Behçet’s disease include evaluation is in order, said Dr. Hillard, professor ease may have acnelike skin le- conventional immunosuppres- of obstetrics and gynecology at the university. Menstruation Quiz sions or as sives such as azathioprine and The age at which girls start their periods has been well as ocular, central nervous corticosteroids; and anti–tumor declining since 1800. Declines in the age of menar- 1. The age of puberty has been declining. system, and bowel involvement. necrosis factor therapy, particu- che up until the 1960s resulted from positive 2. Pubertal development at about age 8 The ocular manifestations can larly with infliximab, according changes such as better nutrition and less infectious years constitutes precocious puberty. be varied and severe, and in- to Dr. Goldstein, who also prac- disease. Since then, however, declines in the age of 3. Girls begin menstruating at an average clude iritis, uveitis, and retinal tices at George Washington Uni- menarche seem to be related to negative changes age of 13 years. vasculitis. Behçet’s disease also versity Hospital, Washington. A such as overeating and limited physical activity. 4. The age of menarche has been declining. can be associated with arthritis recent international expert pan- Over the past 20 years, the age of menarche de- 5. Normal menstrual periods last 2-7 days. and meningitis, and any evi- el suggested that anti-TNF ther- clined by 2 months in white girls and by more 6. A girl who has not started menstruating dence of this disorder should apy might be suitable for pa- than 9 months in African American girls. Federal by age 15 years should be evaluated. prompt consultations with oph- tients with severe, organ- data in 1999-2002 showed the average age of 7. In the first year of menses, it’s normal to thalmologists, rheumatologists, threatening disease—patients menarche to be 12.5 years in whites and 12.1 years have chaotically irregular cycles. and gastroenterologists as symp- with two or more relapses of in non-Hispanic blacks and Mexican Americans (J. 8. Menstruation typically cycles every 21-45 toms dictate. posterior uveitis per year—low Pediatr. 2005;147:753-60). The duration of men- days, but a 90-day cycle also is normal. “One of the easiest ways of di- visual acuity resulting from strual bleeding has held steady, lasting 2-7 days per agnosing Behçet’s is the pather- chronic cystoid macular edema, period in 92% of teen girls. “Early” or “late” Quiz Answers: 1. True 2. False 3. False gy test,” said Dr. Goldstein. or active menarche can be defined as 2.5 standard devia- 4. True 5. True 6. True 7. False 8. True The pathergy test, in which a disease (Rheumatology 2007; tions from the mean (ages 9 or 15 years for white 5- to 7-gauge needle is inserted 46:736-41). ■