Ask an Expert: Q&A – September 2021

Question

A 75 year-old woman has had vulval pain for months with dyspareunia. Her main concern is loss of pleasure during sex. She is using Ovestin and KY lubricant without any improvement. She was previously using a corticosteriod cream. Examination reveals a white shiny vulva. I have referred her for a biopsy to rule out lichen sclerosis. What else can I do?

Answer

From Jean Hailes dermatologist Dr Tanja Bohl

I think what you have done is good. Please consider the following:

• If you haven’t done so already take a swab for candida (low vaginal). I realise it’s not something you would normally associate with a 75 year-old postmenopausal woman, but I have been surprised with positive results before.
• If the vulva is white all over I assume you are thinking lichen sclerosis or possibly hypertrophic lichen planus. It is good to avoid steroids until the biopsy is completed as it may interfere with the results.

The following things are for comfort and avoiding aggravating the vulva rather than specific treatment.

• QV Intensive Body Moisturiser can be used as required, it won’t interfere with biopsy results. Often the vestibule is considered ‘inside’, so it’s important she parts the labia minora and gently cleanses and applies the ointment here. Dermeeze ointment is more runny but also good.
• I would ask her to ‘walk me through’ how she cleans her vulva in the bath or shower and after going to the toilet. Again I find this of value – some women will say things like a non-scented, no-soap cleanser and when I run through it they apply it neat! I advise the use of salt water – tiny sprinkle of salt in a nozzle topped bottle – so she can sit on the toilet and squeeze it to cleanse and soothe. If it stings, there is too much salt. There are many variations on this theme, the main thing is to make it doable.
• Cold compresses are useful but if she needs this for relief you should probably make a phone call to prioritise her appointment.
• An antihistamine that sedates – Phenergan 10mg (occasionally 25mg) overnight is sometimes worth trying but again if she is very uncomfortable a referral should be a priority.