Good evening, and welcome to today's webinar. My name is Dr. Christina Lewicki-Gaup, and I'll be moderating tonight's session. During tonight's webinar, we'll take questions at the end of the webinar, but please submit them at any time by typing them into the question box on the left-hand side of the event window. Today's webinar is Vulvar Issues for the Urogynecologist, and we have the pleasure of having Dr. Sherry Lefevre joining us tonight. She specializes in treatment of vulvar and vaginal disorders, and she's the founder and director of the SLU Vulvar Vaginal Disorder Specialty Clinic. Sherry, thank you so much on behalf of the AUG's Education Committee for your time commitment to tonight, and we're really looking forward to your talk. Thank you. As Christina said, I began the Vulvar Vaginal Disorder Specialty Center at St. Louis University about 16 years ago, and this was actually at the urging of my division chair. I am in the Department Division of Urogynecology there, Dr. Mary McLennan, who was a urogynecologist and was seeing so many of these problems herself and really wanted to concentrate on urogyne and not so much on the vulvar and vaginal problems. So she convinced me, because I was willing to go part-time at that point, to go study with Dr. Rudy Golask up in Iowa, and I've been doing this ever since for 16 years, and this is all I do. So I'm excited to speak with you tonight, because as you all probably know, you see quite a few patients who do have vulvar conditions, and I just want to touch especially on just two different subsets of those conditions and the skin condition, and then very briefly at the end, we'll talk about some pain conditions that you're probably are very familiar with and you do see. So obviously, with the urogynecology patient who has problems with incontinence, most of these women are wearing pads, and they wear pads quite frequently, if not all day long, and as we all know, this traps in the moisture, increases the risk for candidiasis, and then most specifically, they can cause problems with the formation of hyperkeratosis or callus formation, which is a condition called lichen simplex chronicus. And it also, for those women who already have an existing vulvar dystrophy, like lichen planus or lichen sclerosis, obviously the pad wearing and the incontinence is going to make both of these worse. So what I want to do today, first I'm just going to kind of go through the different conditions. I'm just going to talk briefly about the lichen simplex chronicus, then lichen sclerosis, then lichen planus, show you some pictures, and then we will go through kind of a basic treatment protocol for that, and then in the end, we'll touch on, like I said, the vulvodynia part of that. So lichen simplex chronicus, extremely common. It's common for me to see in the vulvar clinic, and it is basically epithelial thickening and hyperkeratosis. So anytime the tissues get irritated and there's persistent rubbing, the body is going to try to protect itself, and it's going to start secreting a callus or keratin to do that. And this becomes, for most women, extremely irritating, and it causes a lot of itching. So these patients get into this chronic itch-scratch cycle, where it itches, so they scratch it, and it just keeps building up more and more callus or keratin, which then leads to the typical findings that we see. So if there's minimal amount of hyperkeratosis, you're just going to see some attenuated skin markings, and this is called the kinification, but then that usually continues on and becomes very thick, and you can actually see patients with visible callus on their tissues. So as we said, you know, causes and factors, heat, sweat. You know, a lot of women who are very heavy and sweat a lot and who wear tight clothing, we see this now. Most people are kind of into that yoga pant look, and it's mostly synthetic clothing that doesn't breathe. Lots of women, even without incontinence, will wear panty liners on a daily basis, and this will add to the level of rubbing and callus formation. Contact irritants are very important also, and we're going to talk about those a little bit more in a couple more slides. And then, obviously, people who have frequent yeast infections, psoriasis, or other conditions, this can lead to that lichen simplex chronicus, a buildup of the callus on the tissues. So here's a picture of somebody with pretty much mild to moderate lichen simplex chronicus, and you can see on the labia majora that the tissue is a little bit dusky looking, a little white, and that's a layer of keratin on the tissues. On the clitoris itself, you can see that she has a layer of keratin that's a little bit more visible, and on the labia minora, and with the one on the left side having a little red area of excoriation where she's probably been scratching and has opened the tissue some. So this is very typical of lichen simplex chronicus, and that is fairly mild, but it's more than likely causing a lot of irritation and itching for the patient. Now in this next picture, you'll see somebody who has much more severe lichen simplex chronicus, where she has a very thickened layer of hyperkeratosis. You'll also notice that, especially with the African American or darker pigmented patients, that once they lose that pigmentation, it will never come back. So it will end up leaving that permanent discoloration, and you will also have this layer of callous formation. Now she has also had some loss of normal structure because she's had this so long, and when it comes to trying to distinguish lichen simplex chronicus from lichen sclerosis, sometimes that can be difficult. So if they've had the lichen simplex chronicus for a long period of time, it can start causing some absorption of the normal anatomy. And here is another picture of lichen simplex chronicus. You can see in the posterior aspect on the perineal body and on the labia majora, she has a very thickened layer of callous. Her clitoris is still there, her labia minora there, but she's red and irritated from her pad wearing. So this is very typical, these pictures of lichen simplex chronicus. So we're going to talk a little bit about lichen sclerosis, and like I said, we will talk about the treatment because most of the treatment for all the vulvar dystrophies are very similar, so we're going to talk about that after I finish with the different conditions. The lichen sclerosis is the long-term, lifelong condition. It's progressive. It's not treated. It will continue to get worse. Most likely, it's an autoimmune process. The body is attacking itself, so it's kind of distressing for patients when they find out that it will not go away. They'll have it for life. Most patients with lichen sclerosis have a tremendous amount of itching associated with it. So you will see a small subset who have no symptoms whatsoever, which is a little bit unfortunate for those patients because then they really don't have that symptom to make them go get evaluated. So some of the people who have asymptomatic lichen sclerosis will actually have further progression of their disease before they ever get diagnosed. So the gross appearance that most of us have seen is that thin epidermis with the layer and varying layers of hyperkeratosis based on how they've been treated. It's classically called the cigarette paper or parchment-like tissue, and it extends down around the anal region. For people with lichen simplicis chronicus, what we were previously talking about, they usually don't have any disease back around the anus because the pads don't tend to get back in there because the gluteal folds protect that area. With lichen sclerosis, you're going to have it go all the way around the perianal region for some patients, or for most patients, actually. Here's a picture of somebody with classic lichen sclerosis. You can see how that disease extends down around the perianal region and how you have that kind of parchment-like paper tissue. You can see that she has her clitoral involvement with a lot of hyperkeratosis up there. So this patient has not been treated very adequately at all, and she's still very thickened with the layer of callus and keratin everywhere. And over time, she's not treated and her labia will continue to be absorbed and her clitoris will totally flatten out with stymosis. But once you get them treated, you can stop that progression of disease, but you can't give them back the anatomy that they've already lost. You can see here, which is very common on this patient also, right above the perianal region, that you can see that she's actually, it's not very zoomed in, but she has actually a little tear. And this is very common as the tissues get more callous, and then they have a bowel movement. It actually splits very easily. So a lot of times, they'll say they have a lot of burning or pain with defecation. And if they have any excorations around the introitus on the labia, even urination itself can be extremely painful because it burns when the urine hits those open tissues. Here's another patient who has pretty far-progressed lichen sclerosis. You can see that she has total anatomical changes. She has total loss of the clitoris. In fact, the glands itself has actually been absorbed, and you can't even palpate it at this point. Now, overall, from the standpoint of how her lichen sclerosis has been treated, she looks pretty good. She doesn't really have that thickened layer of hyperkeratosis. Her labia have been reabsorbed. She's had some introital narrowing, and this in itself can be an issue from the urogyne standpoint, is if somebody has not been treated adequately, they can actually close off the whole vagina and cover over the urethral opening. I have a handful of patients who've been referred, and by the time they've gotten to see me, they have a vaginal opening that a small Q-tip is the only thing that can be passed through there. It's so small, and they end up dribbling their urine through that, increasing the risk for UTIs and even pyelonephritis. Now, for the most part, with lichen sclerosis, you don't operate. You can't cut it out. Anything you remove, the tissue that is there is just going to get lichen sclerosis again. The only time I take someone to the operating room is if they do have enough introital stenosis that it's inhibiting their urinary flow. I had one patient who was actually able to urinate fine through the small opening, but she was getting ready to have a major orthopedic procedure, and they wanted to be able to put a catheter in her. So, taking somebody to the operating room just to release those introital adhesions and open up the introitus so that the urethra is visible is also very appropriate. Some of my younger patients who've seen me who unfortunately had progression to the point where they couldn't have intercourse, I will take them to the operating room to open up the introitus and allow them then to be able to participate in intercourse with their spouses or boyfriends. Here is another picture of somebody with lichen sclerosis. It's also fairly well advanced, and you can see that you can actually get adhesion formations posteriorly that go up also. She has a lot of ecchymosis from the scratching that she does at night. She has total loss of her clitoris and fusion of the labia also. And one more, just because I like pictures, and this just shows you all the different varying looks of lichen sclerosis. There is someone who hasn't been treated very adequately. She is very hyperkeratotic, and she has had anatomical changes and needs to be managed and hopefully her tissues will improve. So once again, treatment will not cure the disease. It will improve the tissue. It will give it more stretch, stop it from progressing, any further loss of anatomy, and it also will decrease by treating these people their risk for bulbar cancer. Untreated lichen sclerosis, even lichen simplex chronicus, if left untreated with continued inflammation, does increase a patient's risk for bulbar cancer. Okay, the next bulbar dystrophy we're going to talk about before we talk about treatment is lichen planus. This is an inflammatory disorder. It involves the mucosal and can extend to the keratinized skin. Lichen sclerosis, what we were previously talking about, only affects the external tissues. It doesn't ever affect the vaginal tissues, but lichen planus can. Once again, this is an autoimmune condition. It cannot be cured, but it can be managed. It's a very painful condition. Twenty-five percent of the patients have it limited to the mucous membranes. It's an erosive disease. It can be in the vulva, the vagina, or in the gums of the mouth, and a lot of my patients, they come to me with lichen planus. I'll always ask about their oral health and if they have any redness or swelling in their teeth. A lot of times they'll say, yes, I have lichen planus in my mouth, and that kind of gives you a hint that they might be having lichen planus vaginally. You don't, just because you have it in the mouth doesn't mean you're going to have it in the vaginal vulva area and vice versa. It can involve, like we said, the vagina, and this is something that if they have a lot of disease up in the vagina, you can lead to total obliteration of the vagina. I have some patients that have been sent that have a total vaginal length of maybe just a centimeter because it's been untreated. Symptoms, much more symptoms of burning with this and pain compared to lichen sclerosis. It also has some itching. If they have a lot of vaginal involvement, they will actually have a very copious kind of inflammatory discharge. They can have bleeding, pain with urination, especially, and I want to show you a couple of slides, you see the ulceration. Obviously when the urine touches those tissues, it's going to be extremely painful. So severe disease is sometimes, and this is kind of, I tell my patients, this is the CREOG question, what the gray, white, lacy strands of hyperkeratosis are called, which are Wickenstria. You don't always see that, but you can actually see it sometimes a lot better in the mouth when you look at their gums. You can see these lacy, white strands, and I'll have a picture of that that I can show you. So this first picture is a patient of mine who, this is fairly severe lichen planus. You can see that it's actually extended to the keratinized region, past the labia, encompassing the clitoris. Like the lichen sclerosity, over time it can cause total obliteration of those structures, and once those structures are gone, they don't come back. Majority of patients, when you see them with lichen planus, will not have it this extensive. Initially, usually it's just right in the introitus, and you might notice some kind of ulcerated red, very painful tissues right inside the introitus, and when you touch them with a Q-tip, and that in itself is significant, you know, for lichen planus. It usually doesn't extend out, but in severe cases like this, it does. This picture is someone who has terribly progressed lichen planus. They have lost all normal vulvar structure, the labia, the clitoris, and then you can see very well this picture above Wickenstriat. So this is very classic to what the Wickenstriat looks like. Okay, so now we're going to get to the point which I think is most important for you, is how do you treat these? As you're a gynecologist, obviously you're going to be seeing, and for some patients, you're going to be the first one that actually diagnoses and sees these conditions, because a lot of our older patients don't see their GYNs anymore, and they're just being managed by a primary medical doctor who doesn't always do a pelvic exam on them. So when they get sent to you for their incontinence or their prolapse, you might notice for the first time that there's something, they have a vulvar dystrophy. So what's the baseline treatment for vulvar dystrophy? And we're going to go over each one of these. So the first one is a vulvar care guideline, and almost every vulvar clinic out there, if you can Google vulvar care guidelines, most of them are the same. I actually Googled this a while ago and found that the ones I use, which were given to me by Dr. Rudy Glass, and I've made my own changes to them, his guidelines are basically used by a lot of different people out there. So it's kind of typical for all of us to use kind of the same ones. So the vulvar care guidelines are just, so when I tell my patients, I have a patient that comes in and I treat them for any vulvar vaginal disorder, I say the baseline thing that we have to do is we have to make the vulvar vaginal area a chemical-free zone. And that is extremely important. We live in a world where people just expose themselves to multiple different irritants. And we, you know, the patients are marketed by fragrance and color and everything has to be exciting. And that is actually really destroying a lot of our patient's tissues. And so I tell them we have to make this area chemical-free zone because we have to improve the tissue quality. We cannot add to the irritation by using the contact irritant. And that's what the vulvar care guidelines do. They're there to remove all contact irritants and to improve the tissue quality at the same time. So we actually did a study in our clinic and we looked at all those patients diagnosed with vulvitis that came in to see us. And we basically do the same thing with everybody. We get a detailed history. If there's anything to treat, like we seek yeast, we treat at that point. But many of these patients, when you look at them, they're just inflamed. They're red. They don't have a yeast or BD under the wet mount. They don't have classic local lichen sclerosis. And so a lot of these people, we will just put them on the vulvar care guidelines and have them come back. And looking at those numbers, we found that there was a 50 to 65% decrease in symptoms across the boards of dyspareunia, burning after intercourse, vaginal burning, vulvar itching, and pain using the vulvar care guidelines alone. So this really does show you that many of the symptoms that women are having are because they are using these contact irritants in their daily routine. And so we spend quite a bit of time actually educating our patients on the vulvar care guidelines. These are my guidelines. These are an old copy. This is an old slide. I've updated them since that time. Anybody that's interested in them can go to the FluCare St. Louis University website and you can download them. You can use them. It's fine with me. We actually print ours on purple, as you can see, and this is just so the patients can, you know, sometimes we'll say, oh, I need another purple sheet. It gives them something to remember them by. Also, hopefully it helps them not throw them away when they go home because it's purple and they'll kind of hang on to them. So you can see just by looking at them, it goes over the different laundry products that they should be using or not using, the clothing that they should be wearing, the soaps that we recommend, the different...all the different other things that are recommended for them are on these two pieces of paper. It's actually on paper front and back. And it really takes it down to the detail what they should and should not be doing. So one of the things that's on the vulvar care guidelines and we're going to talk about now, which is the next step for the treatment of the vulvar dystrophies, are the vegetable-based moisturizers. And when I got started 16 years ago, and actually when I got rotated with Dr. Golask and he told me that he was having his patients use olive oil or vegetable shortening, I was like, oh my goodness, you can't do that. And then he would say, well, why not? And that's exactly the thing. Why not? We put all sorts of chemicals in the vulvar vaginal area and patients have no problem using them. But when it comes to asking them to use something natural that they might find in their kitchen, they get a little bit nervous at times. And you just have to explain it to them. When somebody has a vulvar dystrophy and they have their tissues are inflamed, they're dry, they're ulcerated, they're cracking, we need to give them something that they can use that can soothe those tissues that's going to actually help improve the tissue quality. And it's going to, over time, give them...by moisturizing the tissues, it actually helps it respond better to the treatment, which are usually topical steroids. So I'm very, I take a lot of time convincing my patients that this is something that they should be doing. And in the end, I will have to say if there's one thing that we ever do for all our patients is by putting them on a vegetable-based moisturizer, they came back and they have, they're amazed, they love it, and they tell all their friends. So sometimes to kind of push that point home, you just have to kind of show them what's in all these other medications that they're using. By women and young girls and coming in, using the Refresh, using Verplen. And as you can see, they're just full of chemicals. Even when it comes to Premarin, I know a lot of urogynecologists use the Premarin and Estrace, especially on the urethra to help with the incontinence. And I don't mind. If my patients come in and they need to use that on the urethra, I'll show them exactly where they need to put that little dollop of Premarin or Estrace. But I really do not allow them, like them using it a lot in the vagina or the external tissues because it really does burn. And then you can see why, because if you look at the ingredients, it has a lot of alcohol in it and it has the propylene glycol and other things that can be very irritating to the tissue. Badger Cell is just another one. It's full of alcohol, full of chemicals, and it really has no place at all in the treatment of any vulvar condition. And even when it comes down to the lubricants, the Astraglyde and the KY Jelly, once again, just full of chemicals. So with my patients, I tell them, you know, if you're going to need to use a lubricant, I encourage them, especially postmenopausal or even the patients who are younger with lichen sclerosis, they should use a lubricant. You want to decrease the friction to the tissues that they need to use on the natural vegetable-based moisturizers. And that would be extra virgin olive oil, unrefined coconut oil, or the vegetable shortening. So here we have the slide of the natural vegetable-based moisturizers. You can see Spectrum, extra virgin olive oil, coconut oil, or just mechanically pressed whatever the vegetable oil is. That's 100%. That's all they are. Crisco, which is the shortening. So most of my patients, when you ask them to use shortening, what do you mean? You have to say, well, it's Crisco. I mean, it's a brand. It doesn't have to be Crisco. It can be generic vegetable shortening, but that's kind of like we all associate Kleenexes with that brand. But it does have two, besides having the natural soybean, palm oil, and the diglycerides, it does have two preservatives in it. Ideally, I would love all my patients to use Spectrum, but it's a little bit more expensive, and it's sometimes hard to find. But I can say of all the patients, like I said, I've been doing this for such a long while, the Crisco works very well. And in terms of things, it has many less chemicals in it than anything else that they would be using. Okay. So that brings us to the next thing, our skin protectants. So the vegetable shortening, the olive oil, the coconut oil, they improve the tissues, they give it stretch, they help heal it, but they're not really good protectants because your body absorbs them. So they don't stay on the skin. They actually get absorbed very quickly. So if somebody is wearing a pad every day, or maybe they are swimming, and they're part of a water aerobics class, and they really don't want to give it up, you want to protect that very sensitive, irritated tissues with a skin protectant. And Vaseline, A&D ointment, or zinc are usually the ones that you can pick from. I personally prefer Vaseline. A&D does have crossovers with wool allergies, but some people will actually get more itching when they use A&D. And then zinc is a great skin protectant, but however, it's very drying. A lot of these patients, they put the zinc on, and it dries out their tissues, and they're already too dry. So I actually prefer they would use Vaseline. The next treatment would be the steroid ointment. So when somebody has a vulvar dystrophy, you're going to have to treat them. And the steroids, topical steroids, are the mainstay of treatment. Now, I only use ointments, and I don't use cream. And the reason that is the case is because you can see the different makeup of them. The creams are 50% water, 50% oil, versus the ointments were 80% oil and only 20% water. The cream, though they kind of go on smoother and they treat larger areas, they actually contain skin sensitizing preservatives that can really irritate the tissues. So I tend not to use creams ever on the vaginal, excuse me, on the vulvar tissues. The ointments are better because they also promote more absorption of the active ingredients. They sit there, they allow the steroid itself to be absorbed more thoroughly than the cream does and they don't sensitize the tissues because they don't have those preservatives. A lot of times, you know, the ointments themselves, since they're kind of that Vaseline base, actually act as a kind of contact bearer for the patient. So some people find that they don't need to use the Vaseline as much if they're using their ointment. Okay, so when it comes to the overall treatment for the vulvar dystrophies, the first thing you need is roll out any contributing factors and candidiasis is a big one. A lot of women who are wearing pads on a frequent basis are leaking. Even they tend to, some of the heavier patients, older patients, tend to be diabetics. So they're extremely high risk of having recurrent yeast. So you definitely want to make sure that you're treating your yeast. I'm not a big fan, as you could probably imagine, of the vaginal Terrazoles or any of the creams because they can be very irritating. So if somebody does have yeast and they have the lichen simplex chronicus or the lichen sclerosis, you're definitely going to want to mix your steroid with some nice statin ointment for the outside so that can be treated. And then I tend to use oil treatments by Flucan. And if somebody does have a resistant yeast, which if they're not responding to your azole treatment, you might want to do eventually a yeast culture on them. And if you can get their sensitivities or you can get the species and it's a candida glabrata, you can pretty much be sure that's going to be totally resistant to the azole and then you're going to have to treat them either with nice statin or I use a lot of vaginal boric acid for that. So you want to make sure you treat your contributing factors. You want to remove all contact irritants. So the vulvar care guidelines are extremely important in the treating of the vulvar dystrophies because they do make a difference. Encourage limited pad wearing for those patients who are incontinent but are just very mildly incontinent. And I tell my patients, you know, if you're wearing a pad just for the in case, you know, I leak a little bit and the reality is you only leak when you cough or sneeze and even then it's just a little bit, I'd much rather you change your underwear a couple times a day than wear a pad all day long. If you're at home and that, you know, that should be something that you should be able to do. If patients, you know, obviously have severe incontinence where they are soaking through their underwear and their clothing, then they're going to have to wear a pad and they're going to just have to be very good at using a lot of the vegetable-based moisturizers and using a skin protectant to decrease the rubbing of those pads. Ideally, if you're a gynecologist, you can hopefully make them dry but we know that's not always the case. So, and then you want to treat them with your steroid ointment. Now we're going to talk really briefly about, I forgot to put the slide in on this, about which ointment to pick. In the literature, most people, you know, you read about lichen sclerosis and you always see the steroid clobetazole associated with that. I am not a big clobetazole fan. We actually did a study I guess about eight years ago looking at all our lichen sclerosis patients and we found that almost every single one of them, 98%, were adequately managed on a moderate potency steroid. The steroid I tend to use is trimethylamine, 0.1%. I rarely ever use clobetazole. Clobetazole is actually so strong that it can become a contact irritant itself and if somebody is super hyperkeratotic, then it, you know, might be the one to go for initially. But as soon as that layer of keratosis is decreasing and you're going to manage your patient just on maintenance level dosing, you don't want to use clobetazole. It's too strong. So the trimethylamine is the one I recommend. If I have to go up, if I have somebody who's not responding to the trimethylamine, I usually tend to go up to Lidex next rather than jumping to clobetazole. Now if I have somebody with severe, especially the lichen simplex chronic, there's a really severe thick callus, I might start off with clobetazole. Have them come back, you know, in two, eight weeks or 12 weeks. If they've had the great response, then get them on a much lower potency steroid. Now with the lichen simplex chronicus, you should be, over time, be able to cure that if you stop the inciting factor. However, you need to make sure you treat them long enough. So many patients are told, use the steroid until your itching stops, then stop using it. Well, then it just comes right back again. So I always put my patients kind of on the tapering regimen. I get them, kind of hit it hard, get rid of the keratosis, start tapering them down and then treat it fully and then very slowly take them off. If you stop steroid use quickly, you're going to get something called steroid rebound. They're going to start itching again and then you're going to just be back to the beginning. So you definitely want to treat those patients with lichen simplex chronicus for an extended period of time until it's all resolved, their tissues look good, they're moisturizing and then slowly taper them off. With the lichen sclerosis, you're going to treat those patients initially more frequently and then you finally taper them down to a maintenance level to where they are asymptomatic. And then they stay, most of my patients use their Tram & Soma at least twice a week. I usually don't like them to go less than that even though they're asymptomatic because they'll end up flaring and you don't want them to flare because every time they flare, they're going to have more tissue damage. And then the vegetable-based moisturizers, once again, I just can't say enough about these. It does really improve the tissue quality and makes a difference for the patients. It gives them more supple, stretchy skin and actually even they should be, especially a post-menopausal patient, moisturizing inside the vagina to actually help with the vaginal atrophy and they can be using it as a lubricant with intercourse also. And then once again, you can use the Vaseline as a skin protectant for those that need it. Okay, so that's the vulvar dystrophies. I'm going to just touch on briefly vestibulodynia. So this is a condition that as you as urogynecologists probably see a lot of or come across because it's very common for patients with especially interstitial cystitis to also have vestibulodynia. So vestibulodynia is a form of vulvodynia. So vulvodynia is a catch-all phrase and then it can be broken up into localized vulvodynia, which would be vestibulodynia or clitoral dynia or generalized vulvodynia. Most older women tend to have mostly generalized vulvodynia, a sense of vulvar burning all the time. Anatomically, things look fine. You can't really pinpoint their pain and they just have a sense of burden. So that would be generalized vulvodynia. Vestibulodynia is where it's localized to that vestibule. It's a chronic burning, knife-like pain. I mean intercourse usually becomes extremely difficult, if not at all. A lot of times patients at the beginning will perceive it as a bladder infection because every time they pee it burns because those tissues hurt and they will sometimes get referred to a urologist or urogynecologist prior to being seen even by their urogynecologist. And this, of course, has tremendous psychosocial implications for women because of its impact on their ability not to have intercourse because it's so painful. I'm really not quite sure the etiology of it. It's been studied a lot more, especially since the National Vulvodynia Association came into being. There's actually been grants and research done on it. Primary vulvodynia means it's been present since they started the Menarche. They could never use a tampon. They could never touch down there without pain. Most of the patients have secondary vulvodynia or vestibulodynia, meaning that they've had a normal intercourse, have been able to use tampons in the past, and all of a sudden one day things kind of started getting worse and it developed this pain at the vestibular area. We do know that exposure to topical irritants, you know, which we live in a world of topical irritants. I mean, these young women are going to bath and body works. They're using bath bombs. So many of them are so vaginal vulva are worried and obsessed. They're worried about odor. So using, you know, deodorant fragrances down there. And all those things can definitely cause irritation to the glands and irritate the nerves. We do know that oral contraceptive use in some patients, Dr. Goldstein in DC has done all the research on this, increases, kind of has, probably has a 9.9 increased relative risk for patients to develop vestibulodynia. The thought is there is that the high-dose progesterone down-regulate the estrogen receptors in the tissues and this leads to a higher perception of pain. It also makes the tissues much more readily exposed and irritated by the contact irritants. We do know that recurrent vaginal infections also increase your risk of developing vestibulodynia. And this is probably from two reasons. One, the inflammation caused by the infection itself. And two, the multiple vaginal treatments that most women are given for vaginal infections, whether it be pterosal, whether it be recurrent, you know, treatments of metrogel, that that in itself can over time cause those glands to be inflamed. So the diagnosis, actually here, so vestibulodynia is definitely associated with IC and painful bladder syndrome. So 25% of patients with IC and painful bladder also have volvodynia. And as we all know, and I think we've all seen in our own practices, that those patients with IC or painful bladder syndrome also have associated diagnoses of IBS, fibromyalgia, TMJ, and chronic fatigue syndrome. So there seems to be some sort of neuropathic problem that these patients have a much higher overactive nervous system in a sense, but in perceiving pain. We do know that they share a common embryological origin of the endoderm in the urogenital tissues of the bladder and the vestibular area. So there is kind of an overlap that way. Now, vestibulodynia is actually very easily diagnosed, though it's missed a lot. Because a lot of times the patients look totally normal. They really don't have any erythema, they don't have any structural problems, but it can definitely be there and it's easy to diagnose with the Q-tip test, which I'm sure everybody has heard about. So you just take a Q-tip and then you just, you very gently, and it doesn't have to be, you know, very firm at all, but gently evaluate her Barclayn glands, her periurethral glands, you want to test the lower posterior internal area. And then I ask patients, this slide here shows a scale of 0 to 3, I actually use a Likert scale with all my patients, rating from 0 to 10. And I get a score and I then document that on their chart, because then when they come back, I can retest that again and see if they have improvement. A lot of times the patients will improve, but not enough to where they notice it themselves. It's a very long, slow treatment, the treatment of vestibulodynia. So by checking the scores each time, and especially if they get better, it gives them a lot of hope that things are going in the right direction. So the treatment of vestibulodynia, once again, baseline is a vulvar care guidelines, and this truly does help. Patients who really embrace the vulvar care guidelines, especially moisturizing those gland openings, they can definitely decrease without medication, without any further intervention, their pain scores. So if somebody comes in with, you know, Q-tip test scores of 9, just over 6 to 8 weeks of following the vulvar care guidelines and doing the moisturizing, most patients will come back and have decreased, you know, their scores maybe to 6. Now they might not perceive that, because intercourse is still extremely painful with a vestibular gland score of 6, but knowing by Q-tip touch that it has gotten better gives them a lot of hope. Some patients who actually get much better, and I just had a patient the other week who was feeling great, you know, thought everything was normal, and over the holidays somebody gave her a bath bomb. She had never used one, so she decided to give it a try, and it's amazing. Immediately her tissue started burning. She had everything kind of just ramped up, and she had this horrendous flare. So it kind of does, you know, at that point, those patients that do then go ahead and experiment and start using more contact irritants, almost everyone will find that it does cause a flare of their symptoms, and it's really worthwhile to continue to use the non-fragrant and all the different vulvar care guidelines that are out there. You want to treat any vaginal infection. Patients with recurrent candidiasis are obviously going to have increased risk for pain in those areas, and then the mainstay is the use of the neuropathic pain meds. I use a lot of amitriptyline, gabapentin. I like the Lyrica, the pregabalin, but unfortunately most people's insurances will make them fail. You have to prove that you've tried the amitriptyline, gabapentin first, but, and it's a slow process of starting these people on these medications. These are all associated with some pretty significant side effects, so you have to start out really low, small doses, 10 milligrams of amitriptyline, maybe just 300 milligrams of gabapentin at night, and then you slowly work your way up until you reach a level where they have significant pain relief. A lot of times, if you start with amitriptyline, it might not respond to that. You're going to have to switch to gabapentin, so it's a very slow treatment, and you have to just really counsel your patient from being, you know, patient with that. Now, when it comes to pelvic floor physical therapy, most people read that that's a treatment for vestibulodynia. It's not a treatment for vestibulodynia. It's a treatment for vaginismus, and vestibulodynia can lead to pelvic floor dysfunction vaginismus, but not all patients with vestibulodynia have the pelvic floor dysfunction, so that has to be evaluated. So many of my patients come in, and they've already been on pelvic floor physical therapy, and I examine them, and yes, their vestibular glands are very tender, but they actually have no tenderness at all in the levator anus or the obturator internum, so the pelvic floor is really not doing anything for them. For those patients who have severe vestibulodynia, I never, and who do still have the pelvic floor dysfunction, because there is a higher percentage of that, I still do not start the pelvic floor physical therapy until they start feeling better with the glands, because if the glands are really tender, and they're trying to have intercourse, they're going to just reflexively contract, and it's going to kind of keep that negative cycle going, whereas if you can get the glands feeling better, then work on the muscles, it seems to work a lot better. And then when it comes to the last case scenario for vestibulodynia, which I don't recommend very often, which would be a vestibulectomy, but the literature out there shows anywhere from a 50% to 80% decrease or success rate, 50 to 80% success rate, but none of the papers out there, including one that was actually published from my clinic, really show long-term follow-up. They're almost always short-term follow-up, and I don't think you can make a good judgment on that. Knowing the patients I have who have had a vestibulectomy that still have the vulvodynia, I don't think it's as high as 80% at all. So in summary, for the treatment for the urogynecologist of the vulvar is, one, if you do see someone who has ulceration nodularity within their vulvar dystrophy, I don't know if I touched on this before, you definitely need to biopsy that, because they are at increased risk for vulvar cancer. If you don't feel comfortable biopsying, then refer back to their gynecologist or even your gynecologist to do that, because they are at increased risk. I think you should always start out with a moderate potency steroid. If you need to work your way up, you can. I think everybody, you know, all of us are taught in med school that we should always use the least amount of medication to control the disease process. So I think that definitely applies to the vulvar dystrophy. It's why you use Clavadazole, the highest potency, when you can use something, you know, lower like Trimethylone, and then work up if you need it. You want to always remove all contact irritants. That's extremely important, and I can't stress enough, don't be afraid of the vegetable oils and shortening. They're your friends, and your patients will love them, and it will make a huge difference in their tissue quality and helping them feel better. And that is my presentation. I will be happy to take any questions if anybody has them. Thank you so much, Sherry. It looks like we have some questions coming in. The first one is, any thoughts that you might have on using fractional CO2 laser on the vulva? You know, we're seeing a lot of that, especially maybe for vulvar dystrophy. Yes, so the new fractional lasers, the Monalisa, the Femlis, there's not any good data looking at them for the vulvar dystrophies. They're beginning to be used, and there is some anecdotal data that they can be helpful. I think the biggest way they're going to be helpful are those patients who come who are so inflamed and so, basically not, they're so severe that treating them with a fractional laser could possibly be helped, kind of heal things up quickly. But the bottom line is, even after they've had that treatment, it's not going to cure their lichen sclerosis or their lichen plant. Those are long-term autoimmune conditions. You're going to still have to manage them with a topical steroid to maintain their tissues and to stop flares. So I think in the future, we're going to have a lot more, hopefully, data coming out on the use of those with the long-term vulvar dystrophies. But right now, it's not something that I think is commonplace or should be used right away. As we wait for any other questions, kind of wrapping this up, as a urogynecologist, I'm wondering, before I send a patient to someone like you, do you want biopsies done or do you prefer to do the biopsies yourself? I will have to tell you truthfully, I don't biopsy that often unless I think somebody has cancer. I've seen enough lichen sclerosis, lichen complex chronicus, that I really don't tend to biopsy. I don't tell my residents that. I tell my residents when they go out into private practice, if they have somebody, it's best to biopsy to know what they're dealing with. Once you get started on a topical steroid ointment, you can't do an adequate biopsy. If they've been on the ointment for more than a week or two, you're going to get histological changes underneath all the tissue that makes it difficult for the pathologist to give you the right diagnosis. So if there's any question with what they have, whether it's lichen sclerosis or lichen complex chronicus and you can do the biopsy before you send them, that would be great because if you want to get them comfortable and you want to get them started on a steroid, then that biopsy then becomes more important to do. The bottom line is what I say to my patients sometimes, you know, who are so afraid of biopsy, is that whether it's lichen, if I have a question whether it's lichen sclerosis or lichen complex chronicus, the bottom line is the treatment's the same. And if it gets to the point where I can take you off the steroid and you're doing great on your vegetable based moisturizer and you're not itching and you're fine and you don't need to go back on the steroid, I know it's lichen complex chronicus. If every time we taper you down and you try to get off the steroid and it all comes back and itching comes back, then you know it's lichen sclerosis. Even if it's early lichen sclerosis and have very minimal anatomical changes, which is what makes it kind of difficult sometimes to know. So to me, the biopsy is mostly important if you really think somebody has any type of neoplasia or any changes that are consistent with the VINs or with the squamous cell carcinoma. Got it. We have another question from our audience. Because so many of these conditions have an autoimmune component, do you regularly refer to rheumatology for a full workup? One, I think we all realize how hard it is to get a patient in to see a rheumatologist. With lichen sclerosis and lichen plantus, I don't routinely refer to a rheumatologist. If somebody and I have plenty of patients who come to me and who are having this and maybe have some joint swelling and other issues that I get a history from, then I might refer them at that point, seeing that they're at risk for autoimmune conditions. I do recommend that when patients have the lichen plantus or lichen sclerosis, that they at least get screened for thyroid disorders because I think that's the number one autoimmune condition I see that's very consistent with the lichen plantus and lichen sclerosis. I think we have time for a couple more questions or at least one more from the audience. What about injecting steroids? You know, injecting Kenalog could be helpful. However, some people react poorly to that and it causes a lot of pain and discomfort. I find using the topical steroids, I've never had to worry about and I've never had to inject somebody because they haven't been responding. If somebody is having a really bad flare, especially with the lichen plantus, I would probably opt to put them on a steroid taper oral. I might put them on oral pregnazones to come to know 60, excuse me, 60 milligrams and then slowly taper them down over a month and I think that works a lot better. Even for the vestibulodynia in the beginning, you know, we used to inject them with some steroids in that area and I had so many patients who it just made them feel worse and the use of topical steroids even for vestibulodynia, there's really no, there's no role for that. I mean, the thought was it's going to decrease inflammation but it's not so much an inflammatory condition and that's why they went from vestibulitis, meaning inflammation to vestibulodynia, the ISVD changed the terminology, because it's not infectious, it's not inflammation, it's basically a neuropathic pain med. So I don't use steroids for that treatment. Well, okay, one more question and then we got to probably wrap it up. So is there any role for systemic steroids and lichen plantus, for example, in someone with esophageal involvement? Definitely. So when somebody has lichen plantus that's unresponsive to, even in the vagina, to topical steroids or the vaginal vulva area and especially if it's in the esophagus, which is rare but it has happened and I've had some patients with that, then you're looking at having to use a systemic oral pregnazone and a lot of these patients actually then get seen by their ENT or even if I have somebody in the vulva area who does not respond to topical steroids, might have had a couple, but I've had to refer to dermatology because then they can use the medications I can't use, the methotrexate, the Celsep, very rarely have I had patients in Durham who got put on Lemicade, the immunological agents to control the lichen plantus, but if they're under a lot of stress, they're really immunocompromised, sometimes you have to use the big guns to control this condition because it can be, because chronically inflamed tissue can definitely lead to squamous cell carcinoma and that's kind of the kicker though is that the immunologicals also increase your risk slightly for cancer, but for the patient's comfort you might have to use something like that. Well, Sherry, thank you so much for your time and your dedication and your, you know, this wonderful educational opportunity. On behalf of the AUGS Educational Committee, I want to thank you from the bottom of our hearts. I want to thank the audience too for coming and for their questions and remember that all of these webinars will be posted on the AUGS website, so you can have your trainees, your fellows, whoever, look at this whenever it's convenient for them. I think that concludes our webinar for tonight and again on behalf of the AUGS Educational Committee, thank you so much to Dr. Lefevre. Thank you.

vulvar issues

urogynecologist

webinar

lichen simplex chronicus

lichen sclerosis

lichen planus

vestibulodynia

vestibuloplasty

patient education