It is possible for women to experience some vaginal problems due to hormonal and physiological changes experienced after menopause. However, while some of the problems experienced may be non-serious problems that can be seen in almost everyone, some may be seen rarely. This article provides information about rare health conditions that affect vaginal health after menopause.
Mucous Membrane Pemphigoid Or Cicatricial Pemphigoid
This condition seen in the vagina is a rare autoimmune disease that causes swelling of mucous membranes such as mouth, eyes, nose and vulva. It usually affects the elderly (age> 70 years) and is more common in women. When it involves the vulva, it can cause severe scars that disrupt the vulva anatomy. Clinically, it can be difficult to distinguish from other conditions affecting the vulva, such as lichen sclerosis or erosive lichen planus. Referral to a vulvovaginal specialist for an accurate diagnosis is recommended because although the mucous membrane pemphigoid can respond to a potent topical corticosteroid, it is often very difficult to treat successfully and requires oral corticosteroids or an immunosuppressant medication.
Pemphigus vulgaris is another blistering autoimmune disease that can affect the genital area, although more commonly the oral mucosa, and vulval pemphigus is extremely rare.
Malignant Vulva Skin Lesions
Most malignancies affecting the vulva area occur in postmenopausal women, but vulval intraepithelial neoplasia (VIN) can begin before menopause and is sometimes diagnosed in younger pre-menopausal women. VIN has the potential to progress to invasive carcinoma of the vulva, and women with suspected lesions should be referred to secondary or tertiary care for biopsy and treatment. Approximately 90% of vulvar cancers are squamous cell carcinomas. However, melanoma, basal cell carcinoma, sarcoma, and rarely other types of malignant lesions of the vulva, including Paget’s disease (below) and adenocarcinoma, can occur in the vulva region.
Compared to benign dermatoses, malignant lesions are usually asymmetrical, unifocal or multifocal papules, plaques, erosions and ulcers. As with malignant lesions elsewhere in the body, those on the vulva typically have an irregular shape, texture, color, and distribution. Most vulvar cancer starts in hairless or mucosal areas rather than cutaneous areas. Many women with malignant lesions of the vulva do not have a significant mass. The symptoms of vulvar cancer vary depending on the extent and specific type of cancer involved. For example, itching or pain is associated with squamous cell carcinoma in about 50% of women, while Paget’s disease-related lesions of the vulva can cause a burning sensation and itching, while other women with malignant lesions may be asymptomatic.
Women with symptomatic vulvar invasive cancer may experience itching, a pronounced lump, pain, ulceration, or bleeding. Women with suspicious lesions or who do not respond to treatment for conditions such as lichen sclerosis should be urgently referred to a specialist for examination, biopsy, and, as appropriate, further examinations. Risk factors for vulvar cancer include smoking, VIN, lichen sclerosis, lichen planus, cervical cancer or intraepithelial neoplasia, previous HPV infection, and positive HIV status. Vaginal or anal intraepithelial neoplasia (VAIN, AIN) or invasive cancer of the vagina and anus is less common than vulva malignancy.
Vulva Paget’s Disease
Paget’s disease of the vulva (also called extra-mammary Paget’s disease) is a rare malignant condition that primarily affects older women and may be difficult to distinguish clinically from other skin diseases affecting the vulva. Clinical features include itching and sometimes pain from areas of red, scaly, and crusted skin around the vulva.
Typically, skin lesions will have been present for a while as they are initially asymptomatic or cause only minor irritation. If Paget’s disease is suspected, referral to a vulvovaginal specialist is recommended because accurate diagnosis is based on biopsy results. Other investigations such as colposcopy or pelvic imaging may also be required, as there is an association with other underlying malignancies. For example, Paget’s disease around the anus is associated with an underlying colorectal cancer in about 25 – 35% of people.
Treatment usually involves surgical removal of the lesion, but relapse is common (up to 50%) and more surgery is usually required. Mohs micrographic surgery is the preferred option as it is associated with lower recurrence rates and less extensive surgical excision, if available. Nonsurgical treatments include the use of laser ablation, topical fluorouracil, imiquimod, or photodynamic therapy.
Benign Skin Lesions
A number of benign skin lesions can be found in the vulvovaginal region, including:
On the hairy skin, the “stuck” wart appears as papules. They are benign but can be symptomatic or mistaken for malignant lesions. Removal (eg shaving, scraping, curette, diathermy, or cryotherapy) is usually only indicated if the lesions are painful, increase in size, or to rule out malignancy (excisional biopsy).
Leather tags (acrocord, soft fibroma)
It appears as drooping lesions on a narrow stalk. It is more common in friction areas (medial of the thigh) and in obese women. Shaving excision or removal by cryotherapy is only necessary if painful irritation or inflammation occurs.
Epidermal inclusion cysts
Common in the hairy skin of the labia majora. Treatment is only necessary if the cyst is infected (incision and drainage, and oral antibiotics if appropriate) or if any infection is established, surgical excision is usually large and symptomatic when necessary.
Melanocytic nevi (moles)
It typically appears as dark, soft macules or papules from the skin. They are often less than 6 mm in diameter and uniform in shape, color and structure. However, nevi that are larger, irregular in shape or color are not uncommon in the groin or genital areas. Examine the patient’s general pattern of nevus to determine if a particular spot differs from others, for example an ugly duckling. If you are unsure, arrange for a dermatoscopic examination by a specialist (usually a Dermatologist). Removal is required only for cosmetic reasons or to rule out malignancy.
They are solitary or mostly located on the labia majora, multiple red, purple, blue or blackish papules smaller than 5 mm. Women can apply with these lesions because of bleeding or painful thrombosis, or because they are worried about the appearance. Assurance is available. Larger lesions can be distinguished from malignant lesions due to their uniform shape, structure, and color. Dermatoscopy reveals single or multiple red, purple or blue clots (lacunae) when they are black (and dissolve in a short time) unless they are thrombosed.
It appears as a freely moving, well-defined subcutaneous mass. Excision is indicated only in cases that are painful, increased in size, or exclude malignancy. It is rare in the vulvovaginal region.
Writer: Ozlem Guvenc Agaoglu