A 65-year-old postmenopausal woman comes to the office for evaluation of dyspareunia. The patient recently became sexually active after 7 years of abstinence after the death of her husband. She has a new partner and has pain with intercourse but has had no postcoital or postmenopausal bleeding. The patient was last seen in the office 10 years ago when she underwent treatment for biopsy-proven lichen sclerosus. Her symptoms improved after she was treated with high-dose topical corticosteroids. Pap test at that time was normal. The patient has type 2 diabetes mellitus and hypertension, for which she takes metformin and an ACE inhibitor. She had 3 vaginal deliveries when she was in her 20s. The patient stopped smoking 5 years ago and does not use alcohol or illicit drugs. Family history is noncontributory. Blood pressure is 128/82 mm Hg and pulse is 72/min. BMI is 28 kg/m². Pelvic examination shows a raised, pigmented lesion over the clitoral hood and extending to the right labium majus. Multiple areas of excoriations are noted throughout the vulva. There is no palpable inguinal lymphadenopathy. Speculum examination reveals an atrophic vagina and a cervix with no visible lesions. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf18_b280_8f63_83b255a23ff6_MD0005_00 This patient's raised, pigmented lesion is suspicious for vulvar cancer. Presenting features include dyspareunia, vulvar pruritus, and bleeding. Vulvar cancer has 2 major causes: persistent human papillomavirus infection and chronic inflammation. A common cause of chronic inflammation, particularly in postmenopausal women, is lichen sclerosus, which is an autoimmune inflammatory dermatologic condition. Lichen sclerosus increases the risk for vulvar cancer through a progression from inflammation to vulvar intraepithelial neoplasia to cancer. Because of the increased risk of malignancy, patients with lichen sclerosus require routine examination and treatment with topical corticosteroids. Those whose condition does not improve with corticosteroids or who have atypical lesions (eg, raised, pigmented, fungating) require a vulvar biopsy. In contrast to the thin skin with multiple plaques associated with lichen sclerous, vulvar cancer typically presents as a single, raised plaque or ulcer covering the labia majora. Treatment of vulvar cancer is with surgical excision and possible chemoradiation. (Choice A) Vulvar intraepithelial neoplasia can be treated with laser therapy, surgical excision, or topical treatments (eg, imiquimod). Treatment is deferred until after biopsy. (Choice B) Lidocaine ointment is indicated for short-term relief of vulvodynia, a cause of dyspareunia. Patients with vulvodynia have no associated vulvar lesions. (Choice C) Corticosteroids are the treatment for lichen sclerosus; however, this patient's lesion is suspicious for cancer, which must be ruled out prior to treatment. (Choice D) Topical estrogen treats atrophic vaginitis, which can present with dyspareunia. Patients with atrophic vaginitis have thinned vulvar skin and fusion of the labia minora rather than a raised, pigmented lesion. Educational objective: Patients with lichen sclerosus are at risk for vulvar cancer. Suspicious-appearing lesions (eg, raised, pigmented, fungating) require a vulvar biopsy for diagnosis. References: Lichen sclerosus and risk of cancer. (http://www.ncbi.nlm.nih.gov/pubmed/28124469) Lichen sclerosus: incidence and risk of vulvar squamous cell carcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/27257093)

A 65-Year-Old Postmenopausal Woman Comes to the Office for Evaluation