Menopause Definitions ARHP Association of Reproductive PowerPoint Presentation

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Diagnosing and Treating Vulvar Conditions: Tricks of the Trade Michael S. Policar, MD, MPH UCSF School of Medicine www.PolicarLectures.com

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Objectives Explain 3 differences between lichen sclerosus and lichen simplex chronicus. List the 3 major presentations of Bartholin duct conditions and the preferred treatment for each. List the 3 main causes of vulvar pain and 2 treatment options for each. List the 3 possible conditions in the differential diagnosis of a tender cystic mass of the vulva.

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Presentations of Vulvar Conditions

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The “Itchy Vulva” The Lichens: LS, LSC, LS+LSC Systemic: psoriasis, lichen planus Eczemas: atopic dermatitis, contact dermatitis (irritant, allergic) Fungal vulvitis: candidal, tinea Recurrent genital herpes VIN (Vulvar Intraepithelial Neoplasia)

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Vulvar Skin Complaints: History Nature and duration of symptoms Previous treatment and response Personal, family history: eczema, psoriasis Other sites involved: mouth, eyes, elbows, scalp All medications applied to vulva Antibiotics, hormones, steroids, etc Skin care: soaps, baby wipes, menstrual pads, new clothing, scrubbing, etc New sexual partner(s); barrier contraceptives

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Vulvar Dermatoses New Terminology Old Terminology Lichen sclerosus - Lichen sclerosus et atrophicus - Kraurosis vulvae Squamous cell - Hyperplastic dystrophy hyperplasia - Neurodermatitis - Lichen simplex chronicus Other dermatoses - Lichen planus, psoriasis VIN - Hyperplasic dystrophy/atypia - Bowenoid papulosis - Vulvar CIS

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Lichen Sclerosus: Natural History Most common vulvar dystrophy Bimodal ages: children, older women Cause: unknown; probably autoimmune Chronic, progressive, lifelong condition Most common in Caucasian women Can affect non-vulvar areas Squamous cell carcinoma 3-5% lifetime risk 30-40% SCCA develops with LS

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Lichen Sclerosus: Findings Symptoms Itching, burning, dyspareunia, dysuria Signs Thin white “parchment paper” epithelium Fissures, ulcers, bruises, or hemorrhage Submucosal hemorrhage Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus Introital stenosis and loss of vulvar architecture Reduced skin elasticity

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Lichen Sclerosus: Treatment Preferred treatment Clobetasol (Temovate) 0.05% BID x 2-3 wk, to QD Taper to med potency steroid 2-4x/month for life Testosterone ointment is time honored, but little evidence to support Adjunctive therapy: anti-pruritic therapy Atarax or Benedryl PO, especially at night Doxypin, QHS or topically If not effective: amitriptyline PO Perineoplasty may help dyspareunia, fissuring

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Lichen Simplex Chronicus = Squamous Cell Hyperplasia Irritant initiates “scratch-itch” cycle Candida Chemical irritant, allergen Lichen sclerosus Presentation: always itching; burning, pain, and tenderness Thickened leathery red (white if moisture) raised lesion In absence of atypia, no malignant potential If atypia present , classified as VIN

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L. Simplex Chronicus: Treatment Removal of irritants or allergens Treatment Triamcinolone acetonide (TAC) 0.1% ointment BID x4-6 weeks, then QD Other moderate strength steroid ointments Intralesional TAC once every 3-6 months Anti-pruritics Hydroxyzine (Atarax) 25-75 mg QHS Doxepin 25-75 mg PO QHS Doxepin (Zonalon) 5% cream; start QD, work up

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Lichen Sclerosus + LSC “Mixed dystrophy” deleted in 1987 ISSVD System 15% all vulvar dystrophies LS is irritant; scratching causes LSC DDX: LS with plaque, candida, VIN Treatment Clobetasol x12 weeks, then steroid maintenance Stop the itch!!

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Psoriasis 30% have family history Triggered by stress, drugs, infections, alcohol, cold Usually involves extensor skin beyond the vulva elbows, knees, scalp, nails Genital involvement: mons, vulva, crural folds Pruritis, soreness Red epithelial patches with elevated silver scales Rx: Dovonex, topical steroids

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Lichen Planus Probable autoimmune disease May present as purple, well-demarcated, flat topped papules on oral, genital tissues Erythematous erosive lesions on vestibule or in vagina Vulvar burning or pruritus 50% of women with classic LP will have genitalia involved DDX: LS, syphilis, herpes, chancroid, Behcet’s DX: biopsy essential

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Lichen Planus: Treatment No one satisfactory treatment exists Emollients, vulvar care; treat superinfection Vulva: clobetasol ointment with taper Vagina: Anusol HC 25 mg supp; ½-1 supp PV BID x4 weeks, then taper Short course of oral steroids if necessary Vaginal dilators to prevent scarring Other Rx: Tacrolimus 0.1% (Protopic) BID, Acitretin, methotrexate, Dapsone

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Vulvar “Eczema” Atopic dermatitis “Endogenous eczema” Contact dermatitis: “Exogenous eczema” Irritant contact dermatitis (ICD) Allergic contact dermatitis ACD) Lichen Simplex Chronicus “End stage” eczema

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Atopic Dermatitis Prevalence: 10-15% of population If 2 parents with eczema, 80% risk to children Criteria for diagnosis Itching/ scratch cycle Exacerbations and remissions Eczematoid lesions on vulva and elsewhere (crural folds, scalp, umbilicus, extremities) Personal or family of hay fever, asthma, rhinitis, or other allergies Clinical course longer than 6 weeks

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Atopic Dermatitis: Treatments Avoid scratching; stress management Emollients (bland, petrolatum based) Topical steroids (moderate potency) Intralesional triamcinolone Tacrolimus (Protopic) 0.03% to 0.1% BID Oral antihistamines or doxypin 5% cream Intended mainly to relieve itching Sedation in 20% May cause contact dermatitis

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Contact Dermatitis Irritant contact dermatitis (ICD) Elicited in most people with a high enough dose Potent irritant: chemical burn Weaker irritant: applied repeatedly before sxs Rapid onset vulvar itching (hours-days) Allergic contact dermatitis (ACD) Delayed hypersensitivity 10-14d after first exposure; 1-7d after repeat exposure Atopy, ICD, ACD can all present with Itching, burning, swelling, redness Small vesicles or bullae more likely with ACD

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Contact Dermatitis Common contact irritants Urine, feces, excessive sweating Saliva (receptive oral sex) Repetitive scratching, overwashing Detergents, fabric softeners Topical corticosteroids Toilet paper dyes and perfumes Hygiene pads (and liners), sprays, douches Lubricants, including condoms

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Contact Dermatitis Common contact allergens Poison oak, poison ivy Topical antibiotics, esp neomycin, bacitracin Spermicides Latex (condoms, diaphragms) Vehicles of topical meds: propylene glycol Lidocaine, benzocaine Fragrances

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Contact Dermatitis: Treatment Exclude contact with possible irritants Restore skin barrier with sitz baths, compresses After hydration, apply a bland emollient White petrolatum, mineral oil, olive oil Short term mild-moderate potency steroids TAC 0.1% BID x10-14 days (or clobetasol 0.05%) Fluconazole 150 mg PO weekly Cold packs: gel packs, peas in a “zip-lock” bag Doxypin or hydroxyzine (10-75 mg PO) at 6 pm Replace local estrogen, if necessary If recurrent, refer for patch testing

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General Vulvar Care Measures Wear loose fitting clothing 100% cotton underwear Rinse underwear twice Low irritant soap; no use of fabric softeners 100% cotton menstrual pads www.gladrags.com Mild bathing soaps: Cetaphil, Kiss-My-Face, Basis Vulvar water rinse (or very soft toilet paper) Use vaginal lubricants: Replens, KY, Olive Oil

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Measures for Vulvar Itching Aveeno Oatmeal compresses or tub soaks Tea bags (compress, sitz, or tub) Cold pack, especially before bed Sedating antihistamines at bedtime Emollient during activities Aquaphor, SBR Lipocream, A&D ointment, petrolatum Doxypin 5% cream (20% will become drowsy)

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Rules for Topical Steroid Use Topical steroids are not a cure Use potency that will control condition quickly, then stop, use PRN, or maintain with low potency Limit the amount prescribed to 15 grams Ointments are stronger, last longer, less irritating Show the patient exactly how to use it: thin film L. minora are steroid resistant L. majora, crural fold, thighs thin easily; get striae At any suggestion of 2o candidal infection, use steroid along with topical antifungal drug

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Evaluation: Recurrent VV Itching Symptom diary Detailed search for anatomic causes (e.g., fistula) Saline, KOH slides during symptomatic period Vaginal pH, amine test Candidal culture and speciation, or PCR If at risk for glucose intolerance, check FBS If vaginitis is chronic, severe, recalcitrant, or if oral thrush or lymphadenopathy, consider HIV

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CDC Classification of VVC Uncomplicated VVC (80-90%) Sporadic or infrequent VVC, or AND Mild-to-moderate VVC, or AND Likely to be Candida albicans, or AND Non-immunecompromised women Complicated VVC (10-20%) Recurrent VVC, or Severe VVC, or Non-albicans candidiasis, or Uncontrolled DM, immunosuppression, pregnancy

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VC: SEVEN DAY Therapy Miconazole Monistat-7 2% cream, 100 mg sup Terconazole Terazol-7 0.4% cream Clotrimazole Gynelotrimin 7 1% cream, Mycelex 100 mg tab Rx: 1 application at bedtime for 7 days OTC drugs in italics

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VC: THREE DAY Therapy Butoconazole Femstat 3 2% cream Miconazole Monistat-3 200 mg supp Terconazole Terazol-3 80 mg supp, 0.8% cream Rx: 1 application at bedtime for 3 days Alternative: Miconazole 2% cream BID x 3 days Clotrimazole 1% cream Clotrimazole 100 mg tab 2 QHS x 3 days OTC drugs in italics

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VC: ONE DAY Therapy Clotrimazole Mycelex G-500 500 mg suppository Tioconazole Vagistat-1 6.5% ointment Miconazole Monistat 1 1.2 gm suppository Butoconazole Gynazole-1 2% bioadh cream* Rx: 1 app at bedtime (*anytime) Fluconazole Diflucan 150 mg Rx: 1 tablet PO OTC drugs in italics

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Uncomplicated VVC: Treatments Non-pregnant 3, 7 day topicals equal efficacy and price Recommend: 3 day topical or fluconazole PO Mild or early case: any 1 or 3 day regimen If first course fails Reconfirm microscopic diagnosis Treat with alternate antifungal Rx Candidal culture to speciate No role for nystatin, candicidin

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CDC 2002: Complicated VVC Severe VVC Advanced findings: erythema, excoriation, fissures Treat for 7-14 days of topical therapy or fluconazole 150 mg PO repeat in 3 days Compromised host Conventional antimycotic tx for 7-14 days Pregnancy Topical azoles for 7 days

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Candidia glabrata Vaginitis Main symptom is intense vulvo-vaginal burning, rather than itching KOH : yeast spores and buds, not hyphae Treatments Best coverage (lowest MIC) with butoconazole Imidazoles for 7-14 days Boric acid 600 mg QD x 14 days Topical gentian violet Fluconazole not recommended (by CDC)

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CDC 2002: Complicated VVC Recurrent VVC (RVVC) > 4 episodes of symptomatic VVC per year Most women have no predisposing condition Partners are rarely source of infection Confirm with candidal culture, since often due to non-albicans species Early treatment regimen: self-medication 3 days with onset of symptoms

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RVVC: Treatment Treat for 7-14 days of topical therapy or fluconazole 150 mg PO q 72o x3 doses, then Maintenance therapy x 6 months Fluconazole 100-200 mg PO 1-2 per week Itraconazole 100 mg/wk or 400 mg/month Clotrimazole 500 mg suppos 1 per week Boric acid 600 mg suppos QD x14, then BIW Gentian violet: Q week x2, Q month X 3-6 mo CDC 2002: Complicated VVC

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Vaginal Candidiasis Tips 2/3 of women who believe that the have chronic or recurrent Candida don’t Verify diagnosis with PCR, fungal culture Consider Candida glabrata Different presentation, different treatments Oral or vaginal yoghurt doesn’t work because Lactobacillus strains don’t adhere to vaginal cells Predominant normal flora is L. crispatus, not L. acidophilus or L. bulgaricus

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HPV Infection: Overview Pendulum has swung widely over four decades Controversies persist regarding HPV transmission, treatment, and prevention PH model: STD protection  cancer prevention Primary prevention with HPV vaccine Once infected with HPV Most HPV infections are transient Women < 30 yo; LR types; immunocompetent Persistent HPV infection causes HG lesions Women > 30 yo; HR types; immunosuppressed

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HPV Infection: Overview Therapeutic eradication of HPV is not possible Goal is the control of existing and new lesions Treatment should be limited to High grade pre-invasive disease CIN (cervix), VaIN (vagina), VIN (vulva) Anal IN, Penile IN Genital warts that cause Irritative symptoms of vulva, anus, or penis Cosmetically objectionable lesions Treatment must not be worse than disease

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EGW Treatment: General Principles Advise patient to stop cigarette smoking Evaluate for trichomoniasis; treat if present No one treatment is ideal for all patients or all warts More than one modality may be necessary Should be used sequentially; not simultaneously Treatment must be individualized Size of the warts; extent, location of the outbreak Personal preferences, medical status of patient Experience of clinician Available treatment resources Cost considerations

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Vulvar Papules: Differential Diagnosis VIN or vulvar carcinoma Usually multifocal in premenopausal women Raised with irregular edges but not exuberant Red, white, or hyperpigmented Opaque white with vinegar application Condyloma latum Diagnostic of secondary syphilis Not as exuberant as condyloma accuminata Circular flat papules, usually in clusters If suspected, order syphilis serology (RPR or VDRL) Other lesions: molluscum contagiosum, skin tags, nevi, scars

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Vulvar Papules: Evaluation Exam of vulva, perineum, and anus If questionable, use vinegar for acetowhitening Biopsy Typical condys do not require biopsy Biopsy atypical condys, VIN, or vulvar carcinoma Cervical Pap smear for multicentric disease If perianal warts, evaluate anus by Pap + anoscopy Test for other infectious conditions GC, chlamydia, syphilis, HIV NaCl suspension for vaginal trichomoniasis

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EGW: No Treatment Small asymptomatic vulvar and vaginal genital warts Non-specific acetowhitening of laba majora, labia minora, or introitus (non-HPV) Vestibilar papillomatosis (non-HPV) In placebo-control groups of women with genital warts, 10-30% of cases resolve spontaneously within 3 months

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EGW: Clinician Applied Treatments TCA or BCA 85-90% Moderate vulvar, vaginal GW; not cervical GW Podophyllin 10-25% Resin is less effective, more irritating than TCA Cryotherapy (liquid N2, cryoprobe) Used for isolated vulvar, vaginal, cervical lesions Office excision Simple surgical excision: scissors or scalpel Electrocautery (coagulation), electrodessication

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Self-Applied: Condylox 0.5%Gel Purified podophylotoxin; derived from podophyllin Mechanism: mitotic spindle poison; blocks cell division Use: Apply BID for 3 days, then four days off Expect response by 4 wks; if so, use up to 8 wks Response rate (8 weeks): 80% of women Pregnancy category C Cost (AWP) is $57 per 4 week cycle

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Condylox R 0.5% Gel Advantages Good short term wart resolution rates Fewer adverse effects than podophyllin resin Shorter course, less expensive than Aldara Disadvantages Must apply correctly, consistently for optimal effect Mild-moderate pain, local irritation may occur Safety in pregnancy has not been established

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Self-Applied: Aldara 5% Cream Immune response modifier Stimulates natural killer cell, T-cell activity Induces a-interferon production from local tissues No antiviral effect or direct tissue destruction Apply to EGW every other day x3, then 2 days off Use Mon, Wed, Fri, then Sat, Sun off Wash off in morning using mild soap and water Expect response by 4 wks; if so, use up to 12 wks Pregnancy category B PHS price is $60 per 4 week cycle

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Aldara 5% Cream Advantages Good short term wart resolution rates Little toxicity; mainly erythema and irritation Pain or irritiation; discontination in < 2% Drug of choice in large vulvar EGW “blooms” in women and for immunosuppressed patients Disadvantages Must apply correctly and consistently May take longer for response than podofilox

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Anal and Perianal Warts 25% women with vulvar warts have perianal warts Vaginal-to-anal self-inoculation + microtrauma Intra-anal warts often 2o to anoreceptive sex If perianal warts, examine for intra-anal warts Anal Pap; anoscopy if lesion extends upward Treatment Imiquimod (Aldara) cream Cryotherapy TCA/BCA

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Genital Warts: Complex Treatments CO2 Laser Extensive or refractory vulvar warts or VIN Topical 5-FU (Efudex): Extensive intravaginal condylomata accuminata Primary or recurrent VAIN Extensive surgical excision or electrocautery Extensive refractory lower genital tract lesions Interferon injections: Refractory vulvar lesions

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PPFA Visit and Cost Distribution 46.4% 25.6%

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PPFA First Line Treatment Analysis

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Single location of lesions ? Treatment Completed Aldara, with Education Materials Patient Presents with EGW Multiple locations No EGW Treatment Algorithm No Yes Patient cleared in < 3 visits

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Vulvar Intraepithelial Neoplasia (VIN) Due to infection with HPV 18 or LSC (no HPV) Graded I-III, based upon severity of atypia Sxs: itching, burning, ulceration 4 P’s Papule formation: raised lesion Pruritic: itching is prominent “Patriotic”: red, white, or blue (hyperpigmented) Parakeratosis on microscopy

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Vulvar Intraepithelial Neoplasia Location Multifocal: premenopause, im’compromised Unifocal in postmenopause May be multicentric Precursor to vulvar cancer; low “hit rate” Smoking cessation may improve outcome Tx: Wide local excision, laser ablation Recurrence is common (48% at 15 years)

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Differential Diagnosis: Dark Lesions Hyperpigmentation due to scarring Lentigo, benign genital melanosis Benign nevi VIN Invasive squamous cell carcinoma Malignant melanoma

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Vulvar Melanoma: ABCD Rule A: Asymmetry B: Border Irrigularities C: Color black or multicolored D: Diameter larger than 6 mm Any change in mole should arouse suspicion Biopsy mandatory when melanoma is a possibility

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Fox-Fordyce Disease Disorder of apocrine glands Found on mons, labia majora, axilla Cyclic pruritis; improves with menopause Treatments: OCs Retinoic acid

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Hidradenoma “Milk line” location (interlabial sulcus) Benign tumor 0.5-2 cm diameter Solid consistency Often umbilicated center Non tender Treatment: shells out easily with excision Path mimics adenocarcinoma

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Paget’s Disease Occurs in milk line Extramammary disease may invovle genital, perianal and axillary areas Lesions are brick red, scaly, velvety eczematoid plaque with sharp border S/S: itching, burning, bleeding Cellular origin unclear Treatment: excision with > 3 mm border from visible margin Local recurrence rate is 31-43%

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Tips for Vulvar Biopsies Where to biopsy Homogeneous : one biopsy in center of lesion Heterogeneous: biopsy each different lesions ELA-Max (10% lidocaine cream) applied 20-30 minutes pre-op may be sufficient for anesthesia Skin local anesthesia Use smallest, sharpest needle: insulin syringe Inject s-l-o-w-l-y Most lesions will require ½ cc. lidocaine or less Stretch skin; rotate 3 or 4 mm Keyes punch

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Tips for Vulvar Biopsies Lift circle with forceps or needle; snip base Hemostasis with AgNO3 stick, Monsels, Gelfoam, hemostatic mesh Separate pathology container for each area biopsied

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Chronic Vulvar Pain Syndromes Vestibulodynia (VBD): painful vestibule Vulvar vestibulitis syndrome Vulvodynia (VVD): painful vulva Dysesthetic (Essential) vulvodynia Pudendal neuralgia Vulvar pain of known cause Lichen sclerosis, L planus, Behcet dz, Crohn dz Dermatitis: allergic/ irritant/ eczema/ LSC Infections: Candida, Herpes, Bartholinitis Trauma, scarring

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Vulvodynia: More Questions Than Answers Little agreement regarding definition, epidemiology, diagnosis, management, etiology, and Pressing need for large-scale, controlled studies to explore these issues in greater detail Defined as chronic vulvar pain in which other pathologic etiologies have been ruled out, but duration of pain is not agreed upon Pain lasting from 3 to 6 months is typically considered to be “chronic”

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Percent of Women <25 25-34 35-44 45-54 55-64 Age at First Onset (y) Vulvodynia: Age-Specific Incidence Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

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Vulvodynia: Ethnicity Percent of Women Hispanic African American White Asian Other Nonwhite Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

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Vulvodynia: Symptoms Pain – Knifelike; with genital area contact Itching – With or without pain Burning – Persistent Dyspareunia – Pain and discomfort on penetration Sexual response – Hypervigilance for coital pain Skin changes – Erythema, scaling, fissures Sadownik LA. J Reprod Med. 2000;45:679-684; Hansen A, et al. J Reprod Med. 2002;47:854-860; Welsh BM, et al. Med J Aust. 2003;178:391-395; Payne KA, et al. Eur J Pain. 2005;9:427-436.

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Vulvodynia: Psychosocial Assessment Women reporting vulvar and nonvulvar pain are twice as likely as asymptomatic women to report: History of depression (P<0.001) Chronic vaginal infections (P<0.001) Poorer quality of life (P<0.001) Greater stress Strongest correlates of chronic vulvar pain are self-report of vaginal infections and stress Bachmann GA, et al. J Reprod Med. 2006;51:3-9.

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Work-up of Patient Presenting with Pain Only Vulvar vestibular syndrome likely (typically younger age)* Pain Alone Normal on examination Abnormalities on examination Diagnosis depends on examination Pain poorly localized and spontaneous Dysesthetic vulvodynia likely (typically older age)† Welsh BM et al. Management of common vulval conditions. MJA 2003; 178: 391-395. ©Copyright 2003. The Medical Journal of Australia - reproduced with permission.

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VVS: Epidemiology 15% RA women: introitus painful to touch ½ “mild”; doesn’t affect activities ½ sig. dyspareunia; ½ asked for help VVS has two common times of onset 1o VVS: onset as teen; present in mother 2o VVS: onset post-partum; no family hx Many causes investigated, none proven Chronic candida, HPV not causes Connection with interstitial cystitis

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VVS: Presentation Symptoms Pain symptoms on touch or vaginal entry Absence of symptoms during daily activities Avoidance of pants with tight inseam Avoidance of tampons due to insertional pain Signs Inflamed patches of skin or regions of vestibule Positive “swab test”: Intense pain during rolling of moistened cotton swab over red areas on vestibule Skin beyond ½ cm of inflamed area non-tender

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VVS: Diagnosis “Definitive test” for VVS (Goetsch) Perform swab test 4% lidocaine with cotton app, wait a few minutes Repeat test; if pain is sig. diminished, dx is VVS ISSVD diagnostic criteria Severe pain on touch or attempted entry Tenderness to pressure localized within vestibule Only finding is vestibular erythema Symptoms must have been present for > 6 months No evidence of vaginitis or vulvar dermatoses

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Vulvar Pain, Burning: Diagnosis Pain mapping KOH suspension for candida If negative, culture and speciate That’s it!!!... In the absence of lesions, no role for Vestibular or vulvar biopsy HPV screening (Hybrid Capture) HSV culture or antibody testing

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VVS: Management Ineffective Therapies Antifungals Topical or systemic antibiotics Antivirals (acyclovir) Dietary restriction of oxalates Interferon injections Laser therapy

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VVS: Stepwise Approach to Treatment Vulvar skin care measures Topical steroids: estrogen, cortisone Local anesthetics Neuropathic pain medications Tricyclic antidepressants Anti-seizure drugs Physical therapy and biofeedback Surgery Vestibulectomy

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Vulvar Pain Measures Acute pain: ice pack applied to vulva Episodic relief (30 minutes before intercourse) Lidocaine Xylocaine jelly 2%, Xylocaine ointment 5% EMLA cream (lidocaine 2.5% + prilocaine 2.5%) L-M-X 4 Cream (4% lidocaine) L-M-X 5 Anorectal Cream (5% lidocaine) Dispense 30 gm tube; limit to 2.5 gm/application Avoid oral contact of partner Avoid benzocaine, diphenhydramine additives

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Vulvar Pain Measures Overnight topical anesthetics Apply ointment to introitus + vaginal cotton ball Topical sedatives for relief if itching Doxepin (Zonalon) 5% cream Start once a day, then work up Systemic Tricyclics: amitriptyline (10-25 mg) QHS Nortriptyline, desipramine fewer side effects Anticonvulsants Gabapentin (Neurontin), carbamazepine (Tegretol)

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Tricyclics for Vulvar Pain Must take daily, not “as needed” May take weeks to “kick-in” May have good days and bad days, even with tx Start at low dose, then work up every week Start with 10 mg…progress to 100-150 mg. Because of sedation, dry mouth, take at bedtime If excessively tired in am, take after dinner Once pain is controlled, slowly taper If too fast, get bounce-back pain, nausea, fatigue

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VVS: Surgical Therapy Woodruff”s vestibulectomy (perineoplasty) Surgical excision of vestibule, with undermining of vagina and “pull through” to cover defect 60-89% cure rate Adverse effects Removal of glands necessary for sexual lubrication 1 month recovery Scar tissue; May mildly disfigure vulva Potential recurrence of symptoms after 6 months

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Vulvar Vestibulitis: Surgery Masheb RM, Nash JM, Brondolo E, Kerns RD. Pain. 2000;86:3-10. Glazer HI, et al. J Reprod Med. 1995;40:283-290. At 6-month follow-up, 60% to 89% of patients show improvement and approximately 10% have deteriorated Higher SES, older age, and participation in psychological evaluation/postoperative sex therapy predict better outcomes Childlessness, deep dyspareunia, and diffuse genital pain predict poor outcomes

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Essential Vulvodynia Pudendal neuralgia is likely cause Seen mainly in older women Presentation Poorly localized pain; diffuse and variable hypersensitivity May cause constant, unremitting burning Altered perception to light touch Vulva and introitus appear normal No effect of topical lidocaine Treatment Low dose TCAD:desipramine, imipramine, amitriptylene Gabapentin, carbamazepine, venlafaxine

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Posterior Fourchette Fissure Tender shallow ulcer or fissure at 6 o’clock of introitus Causes severe dyspareunia (or apareunia) “Paper cut” acute pain Possible causes LS, apthosis, chronic candida, OB laceration, ? atrophy Diagnosis: biopsy usually not helpful

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Posterior Fourchette Fissure Management Emollients and moisturizers Elamax cream 30 min before intercourse Water or oil-based lubricant with intercourse High potency topical steroids; steroid injection Cox: add topical estrogen (Estrace) cream to corticosteroid Local destruction (AgNO3 or electrocautery) Surgery: perineoplasty, Y-V flap

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- National Vulvodynia Associationn www.nva.org - www.thevbook.com Resources V Book chapters: “It Hurts” “Sexual Healing”

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The Vulvodynia Guideline Haefner, HK, et al. Journal of Lower Genital Tract Disease 2005; 9:40-51 www.jlgtd.com Links and Resources ASCCP guidelines The Vulvodynia Guideline PolicarLectures.com Reproductive HC links Vulvar Skin Conditions and Colposcopy

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Patient Resources International Society for the Study of Vulvovaginal Disease: www.issvd.org National Vulvodynia Association: www.nva.org Vulvar Pain Foundation: www.vulvarpainfoundation.org Interstitial Cystitis Association: www.ichelp.org

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Bartholin Duct Conditions Bartholin duct and gland at 5, 7 o’clock cephalad (deep) to hymeneal ring Makes serous secretion to “lubricate” introitus If BG duct is transected or blocked, fluid accumulates Non-infected: BD cyst Infected: BD abcess or cellulitis All treatments are designed to drain and create a new duct

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Bartholin Duct: Infectious Conditions Bartholin duct cellulitis Red induration of lat’l perinuem , no abcess Most commonly due to skin streptococcus Tx: PO cephalosporin, moist heat Will either resolve or point as abcess Treat immunecompromised women aggressively Bartholin duct abcess Fluctulent abcess; pus with needle aspiration Tx: I&D, insert Word catheter x 6 weeks Culture pus for gonorrhea Cephalosporin if cellulitis; metronidazole if anaerobic

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Bartholin Duct: Non Infectious Bartholin duct cyst Nontender cystic mass Treat only if symptomatic or recurrent Tx: marsupialize or insert Word catheter x 6 weeks Bartholin duct carcinoma Most common in women over 40 Can be adenoca, transitional cell, or squamous cell Firm non-tender mass in region of Bartholin gland Suspect if recurrent BD cyst or abcess with firm base after drainage

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Vulvar Ulcer: Differential Diagnosis Genital Herpes Syphilis Chancroid “Tropical STD”: granuloma inguinale, LGV Behcet’s Disease: mouth, eye, genital ulcers Crohn’s Disease: Knife-cut ulcers, GI-cutaneous fistulae Lichen planus, lichen sclerosus

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Genital Ulcers: Management Syphilis VDRL or RPR Chancroid Test for H ducreyi (culture, PCR, DNA) Herpes simplex Early lesion: HSV culture, PCR, or DFA Late lesion: DFA or cytology Type-specific HSV serology Biopsy if Bechet’s or Crohn’s suspected Presumptively treat for “best guess” or syphilis + chancroid

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Chancroid Due to Hemophilis ducreyi 10% also have syphilis or herpes Co-factor for HIV infection Symptoms/ signs One or more painful genital ulcers Regional adenopathy; may suppurate (buboe) Lab: culture <80% sensitive; contact lab before sampling Treatment Azithromycin 1 gram PO Ceftriaxone 250 mg IM F/U in 7 days; treat partners within 10 days

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Herpes Simplex Virus: Organism Tests Sensit Specif Cost Comment PCR +4 +4 $$$$ Not in most labs HSV culture ELVIS rapid +3 +4 $$$ No typing ELVIS std +3 +4 $$$ Reflex typing Cytopathic +3 +3 $$ Phasing out Herpes DFA +2 +3 $$ Scrape; plate Cytology +1 +3 $$ Scrape; plate

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Herpes Simplex Virus Serologic Tests Use only “type-specific” tests for HSV-2 antibody Almost all HSV-2 is sexually acquired HSV-1 antibody orolabial or genitally acquired Envelope glycoprotein G (gG) HSV-type specific assays HerpeSelect-1 ELISA or HerpeSelect-2 ELISA HerpeSelect-1 and 2 Immunoblot G POCkit HSV-2, biokitHSV-2 (point of care) Sensitivity: 80-98%; specificity > 96%

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HSV-2 Serologic Diagnostic Testing History suggestive of HSV but no lesions to test If seronegative, not due to genital herpes If seropositive, HSV lesion or prior infection Culture negative recurrent lesion If seronegative, not due to genital herpes If seropositive, HSV lesion or prior infection Suspected 1o herpes, if initial testing negative and more than 6 weeks prior If seronegative, not due to genital herpes If seropositive, HSV infection confirmed

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HSV-2 Serologic Screening Guidelines for the Use of HSV-2 Type-Specific Serologies, CA DHS 2003

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HSV-2 Serologic Screening At risk for STD/HIV (current STD or HR behavior), offer to select patients [C] if: Patient is motivated to reduce risky behavior Patient is willing to use condoms or Rx consistently Risk reduction counseling will be provided Arguments against screening Limited evidence that counseling or Rx works Limited evidence that condoms will be used Little value if risk reduction counseling not given

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Transmission of HSV-2 to Susceptible Partners with Suppressive Therapy Corey et al, NEJM 2004; 350:11-20 Control Group (N=741) Valacyclovir Group (N=743) RCT of 1,484 hetero couples Valacyclovir 500 mg QD or placebo QD for 8 months Monthly HSV serology for susceptible partners The valacyclovir group showed 47% less HSV-2 transmission Lower frequency of shedding Fewer copies of HSV-2 DNA when shedding occurred

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Prevention of Genital Herpes Incident HSV infection reduced by 1.7% over 1 year 96.4% don’t seroconvert in absence of treatment 1.9% seroconvert with treatment Must treat 59 people to prevent one case/ year Indications may include Discordant couples (reassess annually) Infected persons with multiple partners MSM HIV-positive Counsel regarding condoms, disclosure, abstinence * Discussed at the 2006 Guidelines Meeting

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Genital Herpes and Antiviral Drugs Primary Herpes Shortens median duration of lesions by 3-5 days Therefore, initiate within 6 days of onset May decrease systemic symptoms No effect on subsequent risk, frequency, or severity of recurrences Recurrent Herpes Shortens the mean duration by 1 day Initiate meds within 2 days of onset Best to start with onset of prodromal symptoms Patient should have supply of meds available

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HSV: Adjunctive Therapy Frequent dosing of NSAID (ibuprofen) or aspirin Sitz baths (TID) in cool or warm water or use milk compresses Burrows solution sitz baths (Domeboro) or Burrows compresses To avoid towel drying, use the cool setting of a hand dryer If urinary tract symptoms prominent, urinate in warm sitz bath Topical local anesthetics may provide limited relief

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HSV: Suppression Therapy Acyclovir given continuously to decrease frequency, severity of outbreaks Studies have shown befeficial effect for up to five years Will not affect natural history of HSV infection Prior pattern of recurrences after discontinuation Used for those with >6 recurrences per year After 1 year, discontinue to allow assessment of recurrent episodes Most widely used regimen is acyclovir 400 mg PO BID; may be increased to 3-5 times per day

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Management of Vulvar Hematoma Almost all are due to straddle injuries Initial management Pressure Ice packs Watchful waiting Complex management Use if extreme pain or failure of conservative mgt Incise inside hymeneal ring, evacuate clots Pack with strip gauze, sitzbaths

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Additional References Marzano DA, The bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004 Jul;8(3):195-204 Bauer A, Vulvar dermatoses--irritant and allergic contact dermatitis of the vulva. Dermatology 2005;210(2):143-9. Smith YR, Vulvar lichen sclerosus : pathophysiology and treatment. Am J Clin Dermatol. 2004;5(2):105-25. Fischer G, Management of vulvar pain. Dermatol Ther 2004;17(1):134-49. Edwards L, Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111-6 Foster DC, Vulvar disease. Obstet Gynecol 2002; 100(1): 145-63.