Decreased estrogen levels after menopause result in many changes in vaginal tissue. There is reduced blood flow, decreased collagen content, and mucosal thinning. The pH is also increased. Many women experience symptoms of vaginal dryness, pruritis, dyspareunia, and soreness. Although oral hormone replacement is effective in treating these symptoms, many women and their physicians are choosing to avoid this option in light of reports of increased risks of breast cancer. Topical estrogen preparations provide effective treatment for women who are symptomatic⁴ (Evidence Level A). Several products are available, including conjugated equine estrogen vaginal creams and estradiol vaginal creams, tablets, and rings. Side effects are rare. These products should not be used in women with current breast cancer, undiagnosed vaginal bleeding, or a history of endometrial cancer or thromboembolic disease. They are indicated for short-term treatment. Studies have not been performed to confirm the safety of prolonged use (over 6 months.) In women for whom estrogen is contraindicated, options are limited. For dyspareunia, the use of a water-soluble lubricant should be encouraged. Some women find that topical application of vitamin A and D ointment helps the dryness. Caution should be used when applying lotions to the vulva because some hand lotions contain alcohol or other chemicals that can act as irritants.

Vulvodynia is a condition of chronic pain or burning of the vulva with no clear underlying cause. It is often exacerbated by sitting and relieved by lying down. Occult infections should be ruled out. Many women are treated repeatedly for presumed yeast infections with no definitive diagnosis. Bacterial vaginosis does not cause pain, so if a patient reports ongoing pain from repeated episodes of bacterial vaginosis, vulvodynia should be considered. Tricyclic antidepressants are sometimes helpful⁵ (Evidence Level C), as well as topical steroid ointments and topical anesthetic creams. Gabapentin has been reported to be effective⁶ (Evidence Level B). Sitting on a rubber ring may
relieve some of the discomfort. Pelvic floor exercises have been helpful to some women. Referral to a pain clinic may be indicated.

The most common benign affliction of the female genitalia is contact dermatitis, also called eczematoid or irritant dermatitis. In the geriatric population, common causes include incontinence pads, over-the-counter creams and lotions used to alleviate dryness, detergents, soaps, feminine hygiene sprays, and moisture due to stress or urge incontinence. Also, cleansing the vulva vigorously with a rough washcloth can cause an irritant dermatitis. Women who do self-care should be encouraged to use a mild soap and cleanse the area with their fingers, rinsing it thoroughly and patting dry. If there is some incontinence, pads or undergarments should be changed frequently. The main treatment of contact dermatitis involves identification of the irritant and its removal.

Lichen sclerosus is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes (see Fig. 32.3). Although it can develop on any skin surface, more than 85% of cases occur in the anogenital region where it causes pain and itching. Lichen sclerosus usually occurs in postmenopausal women and is one of the most common conditions treated in vulvar clinics. Vulvar pruritis, which is the hallmark of the disease, may be intense. The classical appearance is thin, white wrinkled skin localized to the labia minora and/or labia majora, although the whitening may extend over the perineum and around the anus in a keyhole manner. The vaginal mucosa is not affected. Diagnosis should be confirmed histologically with a biopsy using immunofluorescent staining. There is an increased risk of vulvar malignancy in patients with lichen sclerosus, so the skin of the vulva should be examined at least
yearly. Treatment is recommended for all patients, even if asymptomatic, to prevent the progression of the disease. Untreated, it can lead to shrinkage of the vulvar skin and introital stenosis. Superpotent topical corticosteroids, such as clobetasol⁷ (Evidence Level A, randomized controlled trial) or halobetasol propionate 0.05% ointment daily for 6 to 12 weeks and then one to three times per week for maintenance, have been shown to be efficacious. Steroid ointments are preferred over creams because creams may contain irritants not found in ointments. For severe lesions, intralesionsal injections of triamcinolone seem to be effective⁸ (Evidence Level B).

Psoriasis on the vulva may appear as an erythematous patch without scales. Because psoriasis is usually multifocal, the diagnosis is usually made by finding more typical areas on other skin surfaces.

Lichen planus may be isolated to the vulva or may be part of a generalized skin eruption. It is uncommon but may present with complaints of vaginal or vulvar soreness, pruritis, burning, or dyspareunia. Papulosquamous lichen planus consists of small, intensely pruritic violaceous papules that arise on keratinized and perianal skin. Hypertrophic lichen planus resembles other hypertrophic lesions and may appear similar to squamous cell carcinoma. A biopsy may be needed to make the distinction. Erosive lichen planus presents with bright red erosions with white striae or a white border (Wickham striae) often visible along the margins. Common locations are the labia minora and the vestibule. Vaginal involvement has been reported in up to 70% of patients with erosive lichen planus. These lesions are persistent and resistant to treatment. Lichen planus has been treated with high-dose corticosteroid ointments. Hydrocortisone suppositories are effective for vaginal lichen planus⁹ (Evidence Level B). Topical tacrolimus has recently been shown to be safe and effective¹⁰ (Evidence Level B) for lichen planus of the vulva.

Bullous pemphigoid is an uncommon rash and is more likely to be seen in the crural folds than actually on the vulva, but it does present with moderate to severe itching. It may begin with erythematous patches that look like hives. After 1 to 3 weeks, the lesions become dark red as vesicles and bullae appear on their surfaces. Peripheral blood eosinophilia occurs in 50% of patients. Diagnosis is by biopsy. Treatment includes controlling itching with an antihistamine, such as hydroxyzine. Topical steroids and oral antibiotics such as tetracycline, erythromycin, or dapsone are used. Unresponsive cases may require oral steroids.

The most common symptom of candidiasis is vulvar or vaginal itching. External soreness and dysuria can also occur. Women with diabetes are more susceptible to Candida infections, especially if their glucose level is uncontrolled. The loss of estrogen after menopause reduces the glycogen layer in the vaginal mucosa and increases the vaginal pH, making the vagina less hospitable to Candida. Candida vaginitis is much less common in the geriatric population than it is in younger women. In obese women with moist areas in the crural folds or beneath the pannus, Candida can cause an intertrigo that is difficult to eradicate. Candida is diagnosed by the finding of branching hyphae on a KOH preparation or by fungal culture. Topical azoles such as butoconazole, clotrimazole, miconazole, terconazole, or tioconazole are the most commonly recommended medications.¹¹ A single oral dose of fluconazole is recommended by the Centers for Disease Control and Prevention (CDC) for Candida vaginitis.¹² Severe cases may require a second dose 3 days later¹³ (Evidence Level A).

The physiologic changes in the genital tract of postmenopausal women make it inhospitable to some sexually transmitted diseases. Chlamydia infection and gonorrhea are extremely rare in the geriatric population. Trichomonas, on the other hand, tolerates the increased vaginal pH and can be found in older women. This organism may continue to be present in an asymptomatic state for months to years, so it is occasionally seen in women who have recently not been sexually active. When the infestation is heavy, symptoms include irritation, itching, and a profuse, thin vaginal discharge, which may have an odor. In 30% to 60% of women with Trichomonas infection, there is a foamy or frothy discharge in the upper vagina. Diagnosis is most commonly made by the visualization of motile trichomonads in a saline wet mount of the vaginal secretions, which is reported as being 60% to 80% sensitive. Culture has high sensitivity (>95%) and specificity (>95%) and should be considered in the presence of elevated numbers of leukocytes and the absence of motile trichomonads or clue cells on the wet mount or when microscopy is unavailable. A deoxyribonucleic acid (DNA) probe is also available and accurate.¹⁴ Trichomonads may be reported on Pap smears, but this is insensitive, and false-positives are common.¹⁵ Liquid-based Pap smears appear to have fewer false-positives.¹⁶ Trichomonas infection should be treated even if asymptomatic because it causes a chronic inflammatory state, which may predispose to other infections. Treatment is oral metronidazole. The CDC recommends a single 2-g dose.¹² For recurrent cases, longer courses, such as 500 mg twice a day for 7 days, can be used. The
sexual partner should be treated. Topical treatments are ineffective. Tinidazole is an alternative treatment for resistant Trichomonas,¹¹ which is also given orally in a single 2-g dose. Both drugs interact with alcohol, so the patient should be cautioned to avoid any alcohol-containing products while taking the medication, and for 72 hours afterward in the case of tinidazole, which has a longer half-life.