Management of Vulval Atrophy and Skin Splits in a 59-Year-Old Postmenopausal Female

Background

A 59-year-old postmenopausal woman, married for 35 years, came to the Clarewell Clinic with recurrent painful skin splits in the genital area, which she had self-diagnosed as herpes simplex virus (HSV). She experienced these symptoms once or twice a month but had not sought medical advice before this visit. Her medical history included hormone replacement therapy (HRT), postmenopausal status, and a latex allergy. She had never been screened for sexually transmitted infections (STIs) and expressed concerns about possible genital abnormalities, emotional strain in her marriage, and a loss of sexual intimacy.

Presenting Problem

The patient reported increasing pain during intercourse and occasional post-coital bleeding, both of which had negatively impacted her self-esteem and intimate relationship. Upon examination, white, atrophic patches resembling a “butterfly” pattern were noted on the vulva, with significant labial atrophy (it means that the skin of the labia (the folds of skin around the opening of the vagina) has become thinner and smaller and fusion of the labia minora (it means that the inner folds of skin (labia minora) may stick together or join partially, covering the opening of the vagina). These findings suggested vulval atrophy, potentially exacerbated by menopausal changes, rather than HSV.

Diagnostic Workup

Diagnostic tests were conducted to rule out infectious causes, including herpes DNA PCR and bacterial and fungal cultures, all of which returned negative results for infections such as HSV-1 and HSV-2. An STI screen was offered but declined by the patient. A biopsy, which could provide a more definitive diagnosis for conditions like lichen sclerosis, was also discussed but declined at this stage. Based on the clinical examination and negative test results, a diagnosis of vulval atrophy with potential lichen sclerosis was made.

Treatment Approach

The patient was prescribed:

A potent topical corticosteroid to reduce inflammation and manage skin atrophy.
A fungal treatment.
An emollient: To soothe the skin and protect the compromised skin barrier.

Outcome

The patient reported significant symptom improvement at a follow-up consultation two weeks after treatment initiation. She felt “normal again,” with a complete resolution of discomfort, though some skin discolouration remained. She adhered to the prescribed regimen and was reassured by the negative results of the HSV and culture tests.

Reflections and Conclusions

This case underscores the importance of thorough clinical assessment and targeted diagnostic testing in patients with chronic genital symptoms. Despite the patient’s self-diagnosis of HSV, the clinical findings revealed vulval atrophy, likely related to menopause and exacerbated by prolonged HRT use. The use of topical corticosteroids and emollients led to a rapid resolution of symptoms, highlighting the effectiveness of this treatment approach for similar cases.

Moreover, the case emphasises the psychological impact of genital symptoms on self-esteem and intimate relationships, stressing the need for holistic care in sexual and reproductive health. Early diagnosis and management of conditions such as lichen sclerosis or vulval atrophy can prevent long-term complications like scarring or further skin fusion, improving physical and emotional well-being. This case contributes to clinical practice by highlighting the need to address both physical and psychological aspects of chronic genital symptoms, ensuring a patient-centred approach to care.