Lichen sclerosis, amenorrhea

Question 1

What is lichen sclerosis?

Answer 1

Benign chronic dermatologic scarring skin condition characterized. by inflammation, epithelial thinning and dermal changes causing pain and vulvar itching

Question 2

What group of patients are affected by lichen sclerosis?

Answer 2

Postmenopausal
Prepubertal

Question 3

What causes lichen sclerosis?

Answer 3

Unknown thought to be Multifactorial

Question 4

How do you diagnose lichen sclerosis?

Answer 4

Clinical or vulvar biopsy

Question 5

How can you diagnose lichen sclerosis clinically?

Answer 5

Classic clinical symptoms and physical exam findings

Question 6

What are the classic clinical exam findings for lichen sclerosis?

Answer 6

White thin crinkling skin of the anogenital region
Porcelain white papule/plaques
Introital narrowing; fusion of labia
loss of vulvar architecture
Hypopigmentation; atrophy

Question 7

When should you recommend vulvar biopsy for lichen sclerosis?

Answer 7

Suspicious vulvar lesion
lesion in immunocompromised patient
Un resolved/persistent vulvar lesion
unclear diagnosis
worsening of disease with therapy

Question 8

How do you counsel patient on lichen sclerosis?

Answer 8

Start with explaining chronic condition that can have relapse of symptoms
Vulvar care to help manage symptoms
Discuss treatment with maintenance therapy
Risk of cancer
follow up and when to return if no scheduled follow up

Question 9

What are vulvar care options for patients with vulvar skin conditions?

Answer 9

Cotton underwear; no underwear at night while sleeping
Avoid tight fitting clothes
Avoid soap in affected area; pat dry after bathing
Avoid fragrance spray/soaps in vulvar area
peribottle with urination
adequate lubrication with intercourse

Question 10

What is the recommended management for lichen sclerosis?

Answer 10

clobetasol 0.05% cream nightly for 4 weeks then alternate nights for 4 weeks then 2x weekly for 4 weeks followed by maintenance therapy with lowest dose needed to control symptoms.

Question 11

What is the risk of vulvar cancer with lichen sclerosis?

Answer 11

<5%

Question 12

Where does lichen sclerosis occur?

Answer 12

Typically the anogenital region but can be any skin surface

Question 13

What type of cancer are patient with lichen sclerosis at increased risk for?

Answer 13

Vulvar squamous cell carcinoma

Question 14

What is lichen planus?

Answer 14

Inflammatory dermatologic condition that can affect the skin, mucosa, nails and scalp

Question 15

What is vulvar lichen planus?

Answer 15

Inflammatory condition that causes erosive, papular or hypertrophic lesions on the vulva with or without vaginal involvement

Question 16

What age group is lichen planus typically seen in?

Answer 16

Perimenopause or postmenopausal

Question 17

What are symptoms of lichen planus?

Answer 17

Vaginal discharge, vulvar itching, burning or dyspaurenia

Question 18

What do the lesions look like for lichen planus?

Answer 18

Well demarcated, glazed, brightly erythematous patches or erosions

Question 19

What is the treatment for lichen planus?

Answer 19

Clobetasol nightly for 8-12 weeks
Maintenance therapy 1-4times per week

Systemic steroids if topical not effective

Question 20

What size biopsy should you get for lichen planus or lichen sclerosis?

Answer 20

4mm punch biopsy

Question 21

When is biopsy indicated for lichen planus?

Answer 21

Uncertain diagnosis
with erosive or hypertrophic forms of lichen planus

Question 22

what are second line options for lichen planus and refractory options?

Answer 22

Topical tacrolimus

Intralesional steroids

Question 23

Definition of amenorrhea?

Answer 23

Absence of menses

Question 24

Causes of amenorrhea?

Answer 24

Can be due to hypothalamus, pituitary, ovaries, uterus or vagina

Question 25

Definition of secondary amenorrhea?

Answer 25

Absence of menses for 3 months in women with history of regular cycles and 6 months in women with irregular cycles

Question 26

Definition of primary amenorrhea?

Answer 26

Absence of menses by age 15 in girls with normal growth and secondary sexual characteristics

Absence of menses by age 13 in girls without secondary sexual characteristics

Question 27

What should you think of for girls presenting before age 15 with secondary sexual characteristics with amenorrhea and cyclic pelvic pain?

Answer 27

Outflow obstruction

Question 28

What are causes of primary amenorrhea

Answer 28

Usually a genetic or anatomic abnormality

1. GnRH deficiency -associated with kallman syndrome
2. Functional hypothalamic amenorrhea (anorexia)
3. Constitutional delay of puberty
4. Hyperprolactinemia
5. systemic illness leading to decreased GnRH
6. Gonadal dysgenesis/primary ovarian insufficiency
7. PCOS
8. Outflow tract disorders
9. Imperforate hymen
10. Transverse septum
11. Mullerian agenesis
12. Complete androgen insensitivity
13. 5 alpha reductase deficiency
14. CAH

Question 29

What is a abnormal prolactin level

Answer 29

15-20

Question 30

What are some normal things that can raise prolactin level?

Answer 30

Stress
sleep
Sex
Exercise

Question 31

What is the most common cause of primary amenorrhea?

Answer 31

Gonadal dysgenesis

Question 32

What condition is associated with gonadal dysgenesis?

Answer 32

Turners syndrome

Question 33

What are causes of secondary amenorrhea?

Answer 33

1. Pregnancy
2. Functional hypothalamic amenorrhea
3. PCOS
4. Hyperprolactinemia
5. Thyroid disease