Vulval lichen sclerosus and menopause

• Vulval lichen sclerosus is common but often underdiagnosed condition affecting the skin of your vulva
• Rates are highest among women over the age of 50
• Getting a proper diagnosis and treatment is essential to manage this condition

Vulval lichen sclerosus (vulval LS) is a chronic condition that can make the skin of your vulva sore, itchy and fragile.

It’s most common in postmenopausal women, aged over 50, but can occur at any age and is under recognised and under diagnosed [1, 2]. Vulval LS can be a distressing condition that can have a big impact on your life. Find out here the causes of the condition, symptoms to look out for and advice on how to manage it.

What symptoms can vulval LS cause?

This inflammatory condition affects the skin on your vulva – this is the area on the outside of your genitals, including your clitoris and your labia, which consists of two folds of skin or ‘lips’.

Vulval LS can cause a number of distressing and uncomfortable symptoms on your vulva, including:

• Itching and soreness, which may get worse at night
• Your skin may change colour and may have patches known as plaques, that are pale, white or silvery. If you have darker skin, LS may initially look like vitiligo (a condition in which the skin loses its pigment, causing white patches)
• Small areas of bruising may appear, which look like blood blisters
• Your skin may become fragile, and could split or tear
• Over time, the skin of your vulva may scar and shrink. This can cause your vaginal opening to narrow, which may make sex or other vaginal penetration uncomfortable.

Not everyone will experience all of these symptoms, and the condition can go into remission, which means that your symptoms may not be present all the time. And it’s worth pointing out that vulval LS does not affect your vagina, nor cause any discharge.

Can vulval LS be missed?

Symptoms can sometimes be confused with thrush or vaginal dryness to speak to a healthcare professional if symptoms persist.

Don’t rely on over-the-counter treatments, it’s important you get the right diagnosis and treatment. Early treatment can avoid the more advanced symptoms, when the skin of your vulva can scar and shrink [2].

‘Early diagnosis and appropriate treatment of vulval lichen sclerosus are crucial to prevent the progression of symptoms and permanent scarring,’ says Consultant Dermatologist Dr Sajjad Rajpar.

‘Patients should not hesitate to consult a healthcare professional if they notice any changes in their vulva, as prompt intervention can significantly improve their quality of life.’

What causes vulval LS?

The cause of vulval LS are still not fully understood. It is not sexually transmitted, infectious or caused by an allergic reaction.

LS is increasingly thought by researchers to be caused by an autoimmune condition, where the some cells in your body increase inflammation.

Almost a third of women with vulval LS have another autoimmune condition, when compared to 10% without LS, but it is not clear why this is the case. Thyroid disease and the skin condition vitiligo are those most frequently experienced with people with LS [2]. It sometimes runs in families, so may be caused by an inherited altered gene [2].

RELATED: Thyroid health and menopause

How do I get a diagnosis?

Usually, diagnosis is made by taking a medical history and examining your vulva.

Your GP is often able to make the diagnosis, but you may be referred to a gynaecologist or a dermatologist for more specialist care.

Rarely, a biopsy (a small piece of skin that can be analysed under the microscope) is required to make the diagnosis but if this is needed, it will be done using local anaesthetic.

How is vulval LS treated?

While there is no cure for vulval LS, it can generally be well managed with treatment.

“Managing vulval lichen sclerosus effectively involves a combination of potent topical steroids and regular use of emollients,’ Dr Sajjad says.

‘Around the perimenopause and menopausal, incorporating vaginal hormones is also beneficial.’

The main treatment is a strong steroid ointment which you apply to your vulva. This can sometimes cause burning or stinging when you first apply it, but this usually settles within a week or two and should not stop you using it [3].

The ointment is normally used daily but this can usually be reduced once the condition is well controlled. You should not worry about using topical steroids with LS; they are very safe to use with this condition and will not cause thinning of the skin.

Using emollients or moisturisers to soften and protect the skin is also recommended [3].

Increasingly in the Newson Health clinic, we finding vulval LS improves in women who are using vaginal and/or vaginal hormones. There are cells that respond to oestrogen, progesterone and testosterone throughout your vulva, vagina and surrounding tissues so low levels can affect the these tissues and exacerbate or worsen LS.

RELATED: I’m 27 and perimenopausal: how testosterone helped my symptoms

Vulval LS and genitourinary syndrome of menopause (GSM)

If you are perimenopausal or menopausal, you may be experiencing genitourinary syndrome of menopause (GSM) alongside vulval LS.

GSM is an umbrella term which is a common group of symptoms caused by dropping levels of hormones that can lead to dryness, soreness and itching of the skin on your vulva and surrounding tissues. It can be experienced by up to 70% of women during and after menopause.

Some women find that vaginal hormones, which helps thicken and restore the delicate skin of your vaginal area, relieves itching and soreness, according to the British Society for the Study of Vulval Disease [4].

RELATED: More than ‘a little vaginal dryness’: how vaginal hormones can transform lives

Vaginal hormones can be prescribed as a cream, gel, pessary or flexible ring that sits inside your vagina. These often contain oestrogen and there also pessaries containing prasterone which is a hormone called DHEA that converts to both oestrogen and testosterone. These can be used on their own or with HRT.

Surgery is rarely used to treat vulval LS, unless scarring has caused problems such as a narrowed vaginal opening, which is impacting on your sex life, for example.

You should have regular follow-up appointments until your symptoms are well managed.

RELATED: Read more articles about vaginal dryness and GSM here

What else can I do to manage symptoms?

To help manage the pain and discomfort caused by a flare-up, you can:

• Use an emulsifying ointment or moisturiser, like Dermol 500, instead of soap. These creams can be as a barrier before using the toilet, to reduce stinging and irritation
• Avoid potential irritants like soap, bubble bath, talcum powder, feminine wipes, panty liners, perfumed products or tight trousers
• Use a peri bottle (a simple bottle for washing the perineal area) filled with warm water when passing urine. Spraying warm water around the vulva will dilute the urine and reduce stinging and burning

Does vulval LS bring any other risks?

A small number of women who have vulval LS may develop vulval cancer, but this is very rare when symptoms are well controlled [5].

Regular self-examination is very important. If you notice a change in your symptoms or appearance, particularly any ulcers or lumps, it’s important to talk to your doctor about this.

Dr Sajjad Rajpar is a Consultant Dermatologist and medical director of Midland Skin. Follow him on Instagram @dr.rajpar_dermatologist.

References

1. Wallace H.J. (1971). Lichen sclerosus et atrophicus. Trans St Johns Hosp Dermatol Soc. 57(1):9-30.

2. Popa, A. et al (2024). ‘Vulvar lichen sclerosus: navigating sex hormone dynamics and pioneering personalized treatment paradigm’, J Pers Med. 14(1):76. doi: 10.3390/jpm14010076.

3. Lewis F.M. et al (2018), ‘British Association of Dermatologists guidelines for the management of lichen sclerosus’, British Journal of Dermatology, 178 (4): pp.839-53. doi.org/10.1111/bjd.16241.

4. British Society for the Study of Vulval Disease, ‘What to do at a lichen sclerosus follow-up visit’

5. Halonen P. et al (2017), ‘Lichen sclerosus and risk of cancer’, Int J Cancer, 1;140(9):1998-2002. doi: 10.1002/ijc.30621.

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