What is Lichen Sclerosus?
Lichen Sclerosus(LS) is a chronic inflammatory disorder that affects the skin and mucosa of the genital area in women of all ages, but is most common in post-menopausal women. While LS was first described in 1887, its etiology remains unclear, but increasing evidence and general consensus suggest that an autoimmune mechanism is primarily the cause. As in most autoimmune diseases, we do not know why some women have this disease, but it is more common in women with other autoimmune disorders, or in families with autoimmune disorders. LS occurs when the immune system becomes overactive causing the tissue on the vulva to thicken and scar. The term “lichenification” in reference to vulva disease means thickening of the tissue with increased prominence of the skin markings. Lichenification may be bright red, dusky red, white or skin colored in appearance. The term “sclerosus” means a hardening of tissue.
Lichen Sclerosus is characterized by thickening of the vulva skin causing scar tissue to form. The most common areas of scarring in this disorder are the clitoris, the tissue between the labia majora and minora and the skin between the vagina and anus. The scarring may become so severe that the clitoris can be buried under dense scar tissue, making the glans of clitoris not accessible to touch. This may cause a decrease in sexual sensation and sexual response. This is a common chief complaint when patients present to The Menopause Center with lichen sclerosus.
The effect of Lichen Sclerosus on the labia minora (inner lips) and majora (outer lips) of the vulva is a change in architecture. These two distinct structures often fuse together and shrink, changing the appearance of the vulva. Women will come to the office with the complaint of the vulva having a different appearance. The skin behind the vagina may thicken and become taut. The vulva skin may form fissures, or linear splits in the skin, causing constant pain and discomfort in the vulva. The fissures most often occur in the folds between the labia majora/minora or in the skin behind the vagina. The pain from a fissure or split in the skin often brings the woman to The Menopause Center. The disease may extend behind the vagina and around the anus, or in the groin.
The vaginal opening is commonly involved with adhesions forming around the opening, anteriorly (top of the vagina) from the clitoral adhesions and posteriorly (bottom of the vagina) from the perineal body adhesions. These adhesions may decrease the vaginal diameter, with the vagina becoming stiff and less distensible, making sexual relations painful or impossible. Narrowing of the vagina not only can prevent intercourse, but it can make normal urination difficult, as the narrowed vagina can block the urethra, thereby blocking a normal urine stream.
Early Diagnosis of Lichen Sclerosus
Early diagnosis of lichen sclerosus is essential!
Early diagnosis may be difficult as changes may be subtle and many practitioners, even gynecologists, may not recognize early findings of this disease. Lichen sclerosus may be asymptomatic, and the diagnosis is only made from a careful, systematic physical exam of the vulva by your provider. If your provider simply puts the speculum in the vagina for a pap smear without a careful vulva exam, you may want to find a different provider.
Patients most often complain of persistent itching and/or painful intercourse. Other common symptoms include burning of the vulva, discoloration of the vulva skin, cracking, or fissures of the vulva or anus. Some women notice the tissue is turning white, red or brown, and that the architecture of the vulva is different. There may be a pulling discomfort around the clitoris or labia. There may be a decrease in sexual sensation, difficulty with orgasm, or the inability to even have intercourse as the vaginal opening is too tight. Sexual relations of any sort may be too painful and the couple may stop having sexual relation altogether. Each of these symptoms, if present, should be completely addressed by the gynecologist. If the symptoms do not resolve, a biopsy may need to be taken to rule out lichen sclerosus, or the gynecologist may choose to refer the patient to a vulva specialist.
Late Diagnosis of Lichen Sclerosus
Unfortunately, when patients see their menopause specialist, they often have advanced lichen sclerosus. The common history is that the patient has been to the same doctor for many years with the same complaints, or to a series of doctors with the same complaints with no success in treatment. The symptoms persist, despite multiple treatments for yeast, bacteria, and/or vaginal dryness, but no vulva biopsy has been taken.
Additional scarring from advanced lichen sclerosus can be substantially decreased with treatment but the scarring that has already occurred will not return to normal. This is true for the scar tissue covering the clitoris and the architectural vulva changes. Narrowing of the vagina can be treated with various methods as described below. While treatments are available it cannot undo the damage already done by progression of this disease. Early diagnosis is essential.
How is Lichen Sclerosus Diagnosed?
When a patient comes to The Menopause Center for her initial consult, a thorough history is obtained, with an emphasis on her vulva and vaginal problems including a timeline of symptoms and prior treatments. There may be underlying health problems contributing to the vulva problems and this is all included in this extensive history.
A careful and systematic vulva and vaginal exam is performed and signs of lichen sclerosus are noted. Photographs of the vulva are taken for the patient’s record and for the vulva pathologist. A biopsy is taken in the office on the first visit to confirm the diagnosis.
Pathological biopsy specimens are sent to a specialized vulva pathologist. This important diagnosis is often difficult to make with accuracy. The vulva pathologist looks at the specimen under the microscope, reads the office notes and compares his findings to the photograph taken of the vulva. These steps are all very important, with the experience of the pathologist in vulvovaginal pathology being the most important.
On the second visit with your menopause specialist, a colposcopic (microscopic) exam of the vulva may be performed with additional biopsies taken as needed to rule out any cancerous or pre-cancerous disease. Untreated, advanced lichen sclerosus is associated with an increased incidence of squamous cell cancer of the vulva, estimated to be 5 to 7%.
How is Lichen Sclerosus Treated?
The initial treatment for lichen sclerosus requires a specific steroid cream used on the thickened tissue of the vulva and perianal area. The steroid cream is potent and therefore should only be used on the specific thickened areas of the vulva. It is important that each patient understands exactly where to put the steroid cream when diagnosed with LS. At The Menopause Center, when the diagnosis is made, your menopause specialist will review with each patient exactly where to put the cream. Indirect visualization by a mirror is helpful. The vulva photographs provide a visualization of the vulva that many patients have never seen. Patients are sent home with a drawing of a vulva, with their specific areas of disease noted and instructions on using the Clobetasol ointment.
Follow-up in the office is essential. It is difficult, at best, to put the ointment in the right place each time. Direction by re-examination by your menopause specialist is key to treating this vulva disorder. New areas of LS may appear and new areas of adhesions may require a change in therapy.
Further into the treatment protocol, the frequency of the steroid cream is gradually decreased until a maintenance dose is attained. Visits are recommended first every six to eight weeks, then every three months until the disease is controlled with maintenance every six months.
It is important to remember that LS is a chronic disease that requires ongoing treatment and continued follow-up care. Treatment only when symptomatic is not sufficient for optimal control and allows disease recurrence.
If there is no contraindication to topical estrogen cream, a compounded bio-identical hormone vaginal cream is usually recommended. The cream contains estrogen, testosterone and DHEA, all helpful for vaginal health. The cream does not specifically treat lichen sclerosus, but it treats the lower one third of the vagina and helps prevent stenosis or narrowing of the vaginal opening. In more advanced disease, progressive dilators are recommended for use with the estrogen compounded cream to keep the vagina open.
Advanced Treatment Options Available at The Menopause Center:
I have followed the evolving studies and case reports, and spoken often to other vulva specialists concerning the success obtained with the Mona Lisa Touch CO2 laser in treating lichen sclerosus. I have been watching the development and progress of the CO2 laser being used to delay or reverse the progression of this insidious vulvovaginal diseases. I now have enough information, both anecdotal and from published studies to be confident in offering the Mona Lisa Touch laser therapies in my office.
The MonaLisa Touch CO2 Laser with Dual Probe Therapy is now available in The Menopause Center. In use now for several years, the MLT is a certain type of laser that treats vaginal tissue, plumping up thin tissue, thereby increasing the body’s production of fluid and lubrication of the vagina.
The newer lasers now have “Dual Probe Therapy,” meaning it has a different probe for laser of the vulva. The laser beam goes down to a certain level of the vulva skin and can improve lichen sclerosus. Applied in this way, laser energy may increase the production of collagen in the vulva skin and mucous membranes leading to healthier tissue. The response to laser therapy of lichen sclerosus is different in each woman, but is preferred by some women to control the disease. Steroid cream may be needed in addition to the MLT treatments, but in fewer areas of the vulva. LS is extremely variable, and thus an exact timeline depends on the response.
The Mona Lisa Touch is FDA cleared for incision, excision, ablation, and coagulation of body soft tissues. Note that there is no specific indication for the use in Lichen Sclerosus or any other specific disorder.
Platelet-Rich Plasma
You may be familiar with platelet rich plasma (PRP) being used to help athletes repair their damaged joints or ligaments, thus avoiding surgery. PRP has been used for a multitude of problems with varied success.
PRP has been shown to improve lichen sclerosus of the vulva in some women.
Over the last few years, both in Europe and in the United states, improvement has been found in many women treated with PRP. The idea behind this therapy is that we can heal ourselves, at least to some degree, by the injection of platelets and plasma from our own blood into the lichen sclerosus of the vulva. PRP contains growth factors and nourishing substances that may help improve new blood vessel formation in the unhealthy vulva area with the potential to significantly improve LS. It is available along with laser therapy or steroid topical therapy as a facilitator for healthy tissue.
The procedure for PRP treatment is that blood is drawn from the patient’s arm in the usual fashion, then put in a centrifuge to spin the blood down, separating the platelet rich plasma from the part containing red blood cells. The platelet rich plasma is then drawn into a syringe and reinjected under the patient’s vulva skin in the areas of lichen sclerosus.
Please note that PRP treatment is not stem cell therapy, and thus has fewer potential side effects and a much lower price. Treatment of lichen sclerosus with PRP is not an FDA approved treatment for lichen sclerosus.
Surgical Treatment of Adhesions Covering the Clitoris
The adhesions that cover the clitoris are often formed before the patient has a firm diagnosis. This is most distressing to women, as the area can burn, itch, or pull or can become infected due to cysts that can occur under the scar tissue. The loss of the glans of the clitoris under scar tissue can decrease a woman’s sexual sensitivity and can decrease sexual response. The goal of this procedure is to incise the scar tissue of the hood of the clitoris and push it back, making the clitoris more visible and functional. It will not make the tissue normal, but it can improve comfort and sexual function. The surgery may be beneficial after control with steroid topical treatment is accomplished and the topical steroid will be required after the surgery, so the adhesions do not re-form.
The procedure is performed in the office under local anesthesia using small probes and small scissors, the scar tissue covering the clitoris is excised. This procedure will reduce the adhesions covering the clitoris about 50% to 75%. The glans of the clitoris, in most cases, is more accessible following this procedure.
Treatment for lichen sclerosus is very person specific, and is personalized to each patient’s specific disease and symptoms. At The Menopause Center, Dr. Melinda Hall has a specific interest in lichen sclerosus and years of experience in this disease.