In part 1 of our series or articles on vulvo-vaginal health in menopause, we covered how the drop in oestrogen levels, can cause symptoms of genitourinary atrophy and the options for improving these symptoms, with expert insights from our gynaecologist colleague Dr Lisa Meyer.
Here in part 2, our colleague Dr Harriet Kennedy, a Dermatologist with specialized expertise in vulval dermatology and women’s skin health, shares her knowledge on other vulval skin issues that often occur during menopause. Below, Dr Kennedy discusses common conditions, symptoms, and when to seek medical advice. Whilst the narrative around menopause in Western culture has often been relatively negative, it is good to remember that many issues such as heavy /painful periods, PMS, features of PCOS and as Dr Kennedy mentions below thrush, tend to improve (or resolve) in menopause.
Vulval skin changes at menopause
The vulva is the external genitalia of people assigned female sex at birth and includes the mons pubis, clitoris, labia majora and minora, perineum and perianal skin. Vulval tissues are responsive to hormone levels and a number of changes can occur with the drop in oestrogen at menopause.
Changes to the vulva over the menopausal transition can include include dry skin, reduced lubrication and discomfort with sex, skin thinning and irritation. These changes may be symptomatic in themselves; a condition called “Genitourinary syndrome of menopause” or “vulvovaginal atrophy”. These changes can also make other skin conditions more symptomatic, in which case it’s important to seek medical assessment.
A positive change that occurs at menopause can be that thrush caused by the yeast candida is less common after menopause unless oestrogen replacement is used.
Conditions often diagnosed around the time of menopause
Some skin conditions affecting the vulva are more likely to be diagnosed around or after menopause. At the current time it’s not clear whether this is because of hormonal changes at menopause causing these conditions, or whether symptoms associated with menopausal changes prompt medical examination resulting in longstanding skin issues to be noted and diagnosed for the first time. It is important to note, though, that the conditions covered below can present and be diagnosed at any age, including childhood.
Vulval skin conditions that may be diagnosed around the time of menopause include:
- Vulval eczema
- Seborrhoeic dermatitis
- Vulval irritant or allergic contact dermatitis
- Vulval psoriasis
- Lichen sclerosus
- Lichen planus
- Autoimmune conditions including pemphigoid
Vulval dermatitis (also known as eczema) is very common and has a number of genetic (internal) and environments (external) causes. The commonest genetic eczema is atopic eczema. Atopic eczema typically affects cheeks and faces in babies, skin folds in older children (arm creases, necks, behind the knees) and hands in adults. But skin involvement can be generalised and the genital skin can be involved at any age. Atopic eczema is caused by skin barrier dysfunction a tendency to develop skin irritation.
Seborrhoeic eczema often involves ano-genital skin as well as the scalp (dandruff), eyebrows, central chest, underarms and groin folds. It’s associated with an overgrowth of common skin micro-organisms including the yeast malassezzia. Whilst it’s common for people to have malassezzia yeast on the skin, for some, our body’s immune reaction to the yeast can lead to inflammation, itching and flaking.
Contact dermatitis is eczema related to the skin being exposed to irritants or chemicals that trigger allergy. Irritant contact dermatitis is very common in women after menopause due to contact with urine or pads worn for bladder leakage. Allergic contact dermatitis to sanitary pads has also been reported. Fragrances and preservatives in personal care products can also cause allergy in the vulva. It’s recommended that all products (e.g. washes and moisturisers) used on vulval skin are fragrance- free. Use of ‘feminine hygiene products’ such as specialised washes or wipes should be avoided.
Vulval dermatitis is usually well managed with good skin care by avoiding irritants, using moisturisers and barrier creams and low-potency topical corticosteroid creams for mild-moderate cases. Severe cases may require dermatologist input for further investigation and systemic (whole body/via the blood stream rather than topical) treatment with immune modulatory medication.
Vulval lichen sclerosus and lichen planus
Lichen sclerosus and lichen planus are autoimmune conditions that affect vulval skin. They are often diagnosed around or after menopause. Symptoms can include itching, pain and discomfort with sex. These conditions not contagious and have a genetic cause. A history of other autoimmune conditions such as thyroid disorders, psoriasis, vitiligo, coeliac disease or rheumatoid arthritis may run in the families of people with these conditions.
Lichen sclerosus is not uncommon, affecting around 1% of women, although most have never heard of it! Inflammation in the vulva typically causes whitish skin changes. Bruise-like lesions, blisters and erosions may also be seen. If characteristic skin changes are seen, the diagnosis may be made on examination alone, but in some cases a biopsy is required. Treatment is typically with a strong topical corticosteroid ointment and long-term monitoring is recommended.
Lichen planus is less common than lichen sclerosus. It can affect the genital skin, mouth, scalp/hair, nails or cause generalised rashes. Erosive lichen planus is the most common type in the vulva, and, as the name suggests can lead to painful erosions or ulcerations most often around the opening to the vagina (the introitis). The usual treatment is steroid ointments. Severe cases may be treated with anti-inflammatory medication such as prednisone, hydroxychloroquine or methotrexate.
Over time, lichen sclerosus and lichen planus can cause scarring-related changes in the vulva, even causing fusion over the clitoral area and reduction in size of the labia. There is also an association with vulval skin cancer although this risk is thought to be reduced with treatment.
What to do if you experience vulval symptoms during perimenopause
Know you are not alone and that many women experience itch or discomfort in the vulva at this time. Start with good vulval skin care – water or soap free wash in the shower, avoid very hot water, use a fragrance free moisturiser or barrier cream such as vaseline. Vaseline is a good barrier preparation that can seal in moisturising products but is multi purpose helping to reduce friction, reduces contact with irritants like urine, helps with hydration for optimal wound healing and reduces stinging from urine on inflamed skin. It’s cheap and it’s not possible to be allergic to it!” If symptoms are ongoing do not delay seeing your specialist or primary care physician for an assessment so a diagnosis can be made. This assessment includes a discussion of your symptoms, a vulval skin examination and discussion of management e.g. tests and referrals (if necessary) and the treatment and follow-up plans.
Dr Harriet Kennedy, MBChB, FRACP, FNZDS, has experience in a wide variety of dermatological conditions including medical dermatology, rashes and skin cancer. She has special interests in vulval skin conditions, cosmetic dermatology and patch testing for skin allergy. Find out more and how to arrange an appointment to see Dr Kennedy at Auckland Dermatology here:
You can also follow Dr Kennedy on Instagram @skin_nz for more helpful dermatologist tips!
For more comprehensive menopause support, join the waitlist for our upcoming Menopause app-based course. The course will provide step-by-step guidance, evidence-based medical information mindset strategies, and practical tips to help you navigate menopause with confidence. We will be announcing the course launch date soon!
For personalised medical care around the hormonal aspects of menopause ask your doctor for a referral to ERH Associates
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