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Serious Genital Conditions in Menopause

Lichen sclerosus is a serious, chronic disorder.

Lichen sclerosus is a chronic skin condition that causes white, itchy, and sometimes painful patches of skin on the genitals and anus. This skin condition tends to affect women experiencing low estrogen, with higher prevalence in girls before puberty, women who have had their ovaries removed due to cancer or other conditions, and women in menopause. The exact cause of lichen sclerosus is unknown, but it is thought to be an autoimmune disorder. Lichen sclerosus is sometimes, but not always, associated with other autoimmune conditions, such as thyroid disease, rheumatoid arthritis, and lupus. It is not contagious and cannot be spread by sexual contact.

Symptoms of lichen sclerosus include patchy, wrinkly, thin, white skin on the genitals and anus, soreness, itching, burning, pain, bleeding, swelling, changes in urine flow, painful sex, and, in severe cases, scarring. It can develop on other skin surfaces, but, in women, it is most common near the clitoris, on the labia, and in the anal region. Relatively minor rubbing from bathroom wiping or during sex may lead to bleeding and pain due to the thinness of the tissue. Additionally, lichen sclerosus can lead to narrowing of the vaginal opening, which results in pain, tearing, and bleeding during penetrative sex. For menopausal women also experiencing vaginal atrophy (discussed previously here, here, and here), the symptoms can be similar; therefore, it is important to have your doctor perform an exam to determine which treatment is appropriate. Lichen sclerosus should be treated as early as possible to control symptoms and maintain normal skin architecture.

Mild cases of lichen sclerosus can be treated with topical steroids. More severe cases of lichen sclerosus may require oral steroids or other medications, like immunosuppressive drugs, calcineurin inhibitors, or retinoids. Some women benefit from a treatment called fractional laser therapy (MonaLisa Touch). Unfortunately, the treatment is expensive (~$1000 per session with 3-5 recommended) and must be repeated every 6-12 months (one session) since lichen sclerosus is a condition that has no cure. In some cases, surgery may be necessary to remove scar tissue or to correct other complications.

The prevalence of lichen sclerosus has been increasing. Although the exact reason is not known, a study published in JAMA Dermatology in 2022 found that people who had COVID-19 were more likely to be diagnosed with lichen sclerosus the year after they had COVID-19 than people who had not been diagnosed with COVID-19. Other studies have shown a link between COVID-19 and autoimmune disorders. In February 2023, a study published in The Lancet found that people who had been diagnosed with COVID-19 were more likely to be diagnosed with an autoimmune disorder within one year and that those with the risk of developing an autoimmune disorder was highest in people who had been hospitalized with COVID-19. In March 2023, a study published in JAMA Internal Medicine found that people who had been diagnosed with COVID-19 were more likely to have high levels of autoantibodies, which are antibodies that attack the body's own tissues. As in the February study, the authors found that the risk of having high levels of autoantibodies was highest in people who had been hospitalized with COVID-19. Although these studies are suggestive, more research is needed to confirm any link and to determine the exact mechanism by which COVID-19 triggers development of autoimmune disorders.

If you are diagnosed with lichen sclerosus, there are a few things you can do at home to reduce your symptoms:

  • Wear loose-fitting underwear and clothing. Avoid pantyhose.

  • Use unscented soaps and laundry detergent.

  • Change out of wet swimsuits & clothing quickly.

  • Use lubrication during sexual activity.

  • Wear cotton underwear instead of synthetic underwear.

  • Do not use panty liners or wear incontinence pads.

  • Pat your vulva after washing and urinating to dry it. Don't rub.

Other autoimmune conditions in menopause

In addition to lichen sclerosus, there are a number of other autoimmune conditions that are more common in women experiencing menopause. For example: Lichen Planus and Bechet's Disease. The reasons for the increase in prevalence are not fully understood but may be related to decreased sex hormones. A 2017 study in Autoimmunity Reviews found that women who were taking MHT to relieve menopausal symptoms were less likely to develop autoimmune diseases than women who were not taking MHT.

Vulvar dysplasia is a precancerous condition.

Vulvar dysplasia, also known as squamous vulvar intraepithelial neoplasia (VIN), is a type of abnormal cell growth on the vulva. Specifically, it is a change in the morphological structure of the multilayered flat epithelium of the vulva caused by a violation of the growth and development of epithelial cells. It is a precancerous condition, which means that it should be addressed by your doctor before it becomes cancerous and possibly fatal. Vulvar dysplasia is more common in women over the age of 40, and it is more common in women who have had human papillomavirus (HPV) infections. Other risk factors include smoking, early onset of sexual activity, and sexually transmitted infections (STIs). Studies published in the Journal of Lower Genital Tract Disease in 2017 and Gynecologic Oncology in 2020 both found that women who were menopausal were more likely to be diagnosed with vulvar dysplasia than women who were of reproductive age, but more research is needed to understand this correlation. The symptoms of vulvar dysplasia can vary from person-to-person but may include the presence of warts like those observed with HPV infection, swelling, itching, discharge, dryness, itching, ulceration, and whitish plaques or spots. Since some of the symptoms of vulvar dysplasia overlap those of lichen sclerosus and menopause-related vaginal atrophy (as well as other conditions not discussed here), it is imperative that you see your doctor for an accurate diagnosis.

Although neither vaginal atrophy nor lichen sclerosus can be cured, both can be successfully managed by home care, medications, and/or surgery. Untreated vulvar dysplasia may be life-threatening.

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