CF: 56-60

Question 1

51 yo woman p/w 4 yr hx of pruritic vulva. Genital tissue is atrophic. thin, white and excoriated with retraction of the clitoris and constriction of the introitus with some bruising.
Dx?
Next step?
Most likely therapy?

Answer 1

• Lichen sclerosis
• Bx of affected areas
• Corticosteroid ointment

Question 2

What does Bx of lichen sclerosis show?

Answer 2

Thinned epidermis, hyperkeratosis, elongation of the rete pegs

Question 3

Why are postmenopausal women at lower risk of candidal vaginitis?

Answer 3

Decr estrogen–> incr pH–> not amenable to candida

Question 4

Silver scaly lesions on vagina and extensor surfaces?

Answer 4

Psoriasis

Question 5

Why is it important to Bx lichen sclerosis?

Answer 5

Bc vulvar cancer and VIN can both present similarly and are assoc w/ LS, so you must rule them out.

Question 6

Which tends to involve the vagina: lichen sclerosis or lichen planus?

Answer 6

Planus

Question 7

What structures comprise the vulva?

Answer 7

Mons pubis, labia majora and minora, clitoris, vaginal vestibule and glands, opening of urethra and of vagina, hymen.

Question 8

What two ages does lichen sclerosis peak?

Answer 8

Prepubertal and postmenopausal

Question 9

What percent of lichen sclerosis has extragenital disease?

Answer 9

15-20%

Question 10

MC CC with lichen sclerosis?

Answer 10

“Vaginal” (really vulvar) itching that’s worst at night

Question 11

Name 4 things in the Ddx of lichen sclerosis

Answer 11

1. Lichen planus
2. VIN/cancer
3. Vitiligo
4. Psoriasis

Question 12

How does closure of the vaginal introitus occur in lichen sclerosis?

Answer 12

Scratching or intercourse–> tears–>scarring–>narrowing/closure

Question 13

How does dyschezia occur in lichen sclerosis?

Answer 13

Scratching–>scarring–>constriction of anus

Question 14

3 major lifestyle modifications for lichen sclerosis?

Answer 14

1. All white, cotton underwear
2. No irritants to skin
3. No scratching!

Question 15

Medical treatment of lichen sclerosis? Followup?

Answer 15

Corticosteroids- start with potent ointment (clobetasol) and taper down once Sx abate. Continue maintenance dose to ppx relapses of pruritis.
Yearly surveillance to monitor for cancer

Question 16

What glands are at the 5 and 7 o clock locations of labia majora?

Answer 16

Bartholin (greater vestibular) glands

Question 17

How do you treat bartholin gland abscess (2 options)? What is the goal of either of these options?

Answer 17

1. Incision and placement of small balloon catheter into gland
2. Marsupialization
   Purpose of both is to allow drainage of infection over several weeks

Question 18

Typical etiology of bartholin gland abscess?

Answer 18

Polymicrobial

Question 19

45 yo woman comes in with bartholin gland abscess. Whatcha do?

Answer 19

She’s over 40, and BG abscesses in the >40 age group are often assoc w/ cancer. Get her a Bx.

Question 20

What’s a major RF for developing vulvar cancer as a younger woman?

Answer 20

HPV

Question 21

Name 3 big RF for vulvar CA?

Answer 21

HPV
Lichen sclerosis
Smoking

Question 22

Next step after diagnosing vulvar CA on Bx?

Answer 22

Surgical staging w/ removal of primary lesion and ipsilateral inguinal LNs

Question 23

MC type of vulvar CA? Name 2 other types?

Answer 23

MC: SCC

Basal cell, melanoma

Question 24

How do you treat symptomatic vaginal atrophy in post-menopausal woman?

Answer 24

Estrogen cream