Why See A Menopause Specialist?

A Menopause Specialist is one of the few gynecologists in the Washington DC area who specialize in disorders of the vulva. This specialized field of gynecology has been an ongoing area of professional interest for our menopause specialists over the past 20 years, leading to additional certifications and a wealth of clinical experience.

Considered an expert diagnostician of vulva disorders, our menopause specialist sees many patients referred from other gynecologists and dermatologists who need assistance with the diagnosis and treatment of a variety of vulva problems. 

Our menopause specialist is an active member of the International Society of Vulva and Vaginal Disorders (ISVVD), the International Society of Sexual Medicine, and The National Vulvodynia Association.

What are Vulvovaginal Disorders?

Vulva disorders are disorders that occur on the vulva. The vulva includes the mons (the hairy area), the labia majora (large lips, also hairy), the labia minora (small lips that you can see when you spread the large lips, the clitoris and clitoral hood (the hood partially covers the top of the clitoris), the urethra (where the urine comes out), the vaginal opening, the perineum (behind the vagina and in front of the anus. and the perianal area (Area around the anus).

The bottom of the vagina goes from the vaginal opening where the vulva and vagina meet to the top of the vagina where the vagina meets the cervix. (bottom of the uterus) Although any area of the vagina may have a problem, the most common area of discomfort is the vaginal opening or the lower one third of the vagina. This area contains many important structures, the vestibular glands, the hymen, or the remnant of it, and the muscles underneath the vagina that can get irritated and have a muscle cramp, like many other muscles in the body.

The vulva and vagina are both affected by low estrogen and probably low testosterone. Infections may cause itching , burning and discharge from the vagina, but this often affects the vulva at the same time. Both areas have to be addressed (see more about vulvovaginal cancers below).

Vulvas can get skin cancer. The gynecologist is usually the only one who regularly checks that area, but it is a good idea for the patient to look at herself with a mirror every few months to check for new lesions or changes. Vaginal cancers are difficult for the patient to detect. If abnormal spotting occurs or an abnormal, persistent discharge, a thorough vaginal exam needs to be done by a vulvovaginal specialist or gynecologist. 

There are many benign abnormalities of the vulva and vagina that may cause severe symptoms such as itching, bleeding, and pain, however many  vulva disorders are totally without symptoms. Any area with continuous symptoms or a lesion present for more than a month should be evaluated by a vulvovaginal specialist. 

Virtually any skin disorder that occurs in other areas of the body can occur on the vulva. This includes ulcers (like one gets in the mouth), infections of all types, eczema, contact dermatitis, folliculitis, polyps, abscesses. psoriasis, and autoimmune disorders. 

Many STDs infect the vulva and vagina presenting as bumps, ulcers or sores such as genital herpes, warts or molluscum contagiosum. The HPV virus may infect the vulva and perianal area and is associated with vulva or anal cancers if left undetected and untreated. The HPV virus may also infect the vagina and cervix , leading to an abnormal pap smear and potential cancer if undetected.

Vulva & Vaginal Cancers

Vulva cancers are like any skin cancer, but occur on the skin of the vulva. Some of the cancers that may occur on the vulva, are melanoma, basal cell cancer, squamous cell cancer, and even cancers that have spread from other areas of the body. (metastatic cancer).

Vulva cancers usually present in a premalignant stage prior to turning cancerous. It is therefore important that your annual pelvic exam is done with someone experienced in identifying the early stages of these cancers. As these cancers are even more common with aging, it is another reason for continuing annual exams as you age, even after a hysterectomy. Your gynecologist should do a thorough vulva exam before inserting the speculum into the vagina, otherwise your exam in incomplete.

Vaginal cancers do occur, but are much less common than vulva cancers. Vaginal cancers are rare, fortunately, and the symptoms are abnormal spotting or bleeding with sex, an unusual discharge that does not resolve. The gynecologist will do a thorough speculum exam to diagnose vagina cancer.

A wide spectrum of benign, premalignant, and malignant lesions may involve the vulva. The challenge to the clinician is to differentiate between normal variants, benign findings, and potentially serious disease. Many times, a biopsy must be taken of the vulva to definitively make the diagnosis.

Melanomas, basal cell carcinomas and squamous cell carcinomas may occur on the vulva, vaginal opening, anus or buttocks and these areas require systematic exams to complete a total body skin check. Many dermatologists are hesitant to thoroughly examine the genital area when performing routine skin checks in high risk patients. 

Our menopause specialist offers screening of these hard to see areas with the aid of a colposcope and the use of biopsies when indicated.

Contact us for a vulva skin check.

Lichen Sclerosis

Lichen sclerosis is an autoimmune skin disease of the vulva that is often misdiagnosed by medical practitioners. It is more common in women after menopause, but occurs in women of all ages. The cause of lichen sclerosus is not completely understood, but occurs when the immune system becomes overactive causing the tissue on the vulva to thicken and scar. Lichen sclerosis can be associated with other autoimmune disorders, or in families with autoimmune disorders.

Lichen Sclerosis is characterized by thickening of the vulva tissue where it turns white. Scar tissue forms in this disease and  scar tissue commonly affects the clitoris, It may bury the clitoris under dense tissue, making the glans of clitoris to not be accessible under the scar tissue. This may cause a decrease in sexual sensation and sexual response and is very distressing to patients.

Commonly involved in Lichen Sclerosis is the labia minora (inner lips) and majora (outer lips) of the vulva. These two distinct structures  often fuse together and shrink, changing the appearance of the vulva 

The vaginal opening is commonly involved with adhesions forming  all around the opening. This may decrease the vaginal diameter and it may become stiff, making intercourse painful or impossible. The disease may extend behind the vagina and around the anus, or in the groin. The disease is exacerbated by thinning tissue associated with low estrogen in menopause.

The presenting symptoms of lichen sclerosus are most commonly itching and/or burning of the vulva, discoloration of the vulva skin, cracking, or fissures in the vulva or skin around the anus. The patient may complain of a pulling discomfort around the clitoris or a decrease in sexual sensation and difficulty with sexual response. 

Early diagnosis of lichen sclerosus is essential!

Early diagnosis may be difficult as changes may be subtle and many practitioners are not  familiar with this disease. Lichen sclerosis may be asymptomatic, and the diagnosis is made after scarring of the clitoris and narrowing of the vaginal opening have already occurred. While treatment is available, it cannot undo the damage already done by progression of this disease. Untreated lichen sclerosus is also associated with an increased incidence of cancer of the vulva.

Our menopause specialist has a special interest and specific training in detecting and treating lichen sclerosus. Contact us if the vulva or clitoris look different or the vulva looks white.

Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) is a common vulva skin condition that is very itchy. LSC of the genital area most often affects the vulva, groin and/or skin around the anus. Another name for LSC is vulva eczema, although many clinical characteristics are different than eczema in other areas of the body.

The vulva skin can start to itch for a variety of reasons: chronic yeast or other infections, diabetes, hormonal problems, and obesity. Some women with LSC have a long history of sensitive skin, asthma or chronic allergies. The trigger is often unknown and not conclusively identified. 

The skin usually appears thickened with a white color or dark red with excoriations (sores)  from rubbing and scratching. The patient often is treated with various topical treatments with continued scratching of the area. This causes the tissue to thicken more and itch more. Although rubbing and scratching often feels good at first, rubbing irritates the skin and ultimately makes itching even worse, so that there is more scratching, then more itching, then more scratching. This is called the “itch-scratch cycle.” 

Although not dangerous, both the itching and the pain from rubbing and scratching, can be miserable. Many women have had this disorder for years before seeking treatment.

The cause of LSC is not entirely clear, however, LSC starts with vulva irritation that triggers itching. Often times, by the time the patient sees the vulva specialist, the original infection or other initial cause of irritation is no longer present. Common triggers include a yeast or fungus infection, vulva topical medications, moisturizers or lubricants, panty liners, an irritating condom, or any other activity or substance that can irritate the skin and start the itching.  

If you have ongoing vulva itching, contact us. We can help.

“I had terrible itching and burning of my vulva for 5 years and I had been misdiagnosed by 2 previous OB/GYNs.Our menopause specialist knew immediately what the problem was and has successfully treated it for 2 years. I can’t thank her enough.” – LH

Vulvodynia

Vulvodynia, simply put, is chronic vulvar pain without an identifiable cause. The location, constancy and severity of the pain vary among sufferers. Some women experience pain in only one area of the vulva, while most experience pain in multiple areas. 

Vulvodynia is an ongoing pain syndrome of the vulva and/or vaginal opening that cause irritation, itching, burning, or pain in the area for no apparent reason. Exacerbation of the discomfort may be associated with wearing tight clothing, using a tampon or sexual relations. 

The pain can become so severe that penetration during sexual intercourse may become impossible. Even touching the vulva even at the time of a pelvic exam may cause pain.  The reason for these symptoms is often elusive and multifactorial, requiring an expert in vulvovaginal disorders to make an accurate diagnosis and to plan a successful treatment.

There are many successful treatments available. It is a process to desensitize the vulva and it will take several months to control or cure.

Contact us. We can help.