The Vulva Diaries

Dr. Selk interviews Dr. Andrew Goldstein, an obstetrician and gynecologist and the director of the Center for Vulvovaginal Disorders in New York City and Washington DC, about his new randomized control trial studying laser therapy in lichen sclerosus (LS). Topics covered include reasons behind conducting the trial, methodology of the study, results of the study, how to counsel patients about laser for LS, previous research and other evidence on laser for LS, importance of unbiased study design, differences based on type of laser used, and the ethics of counselling patients about treatment.

Dr. Selk interviews Dr. Martha Goetsch who is a long-term researcher and clinician specializing in vulvar conditions at the Oregan Health and Sciences Unit. In this week's episode they discuss some of her recent research on estrogen in vulvar pain. Topics covered include the background and reasons for exploring this area, theories behind the cause of vulvar pain, methods studied to reduce vulvar pain, and results after implementing these methods in post-menopausal women. They also discuss estrogen regimens in post-menopausal patients, differentiating between atrophy/dryness and pain, systemic absorption of topical estrogens, how long to treat with estrogen post-menopause, reassuring patients about estrogen use, the utility and importance of using lidocaine in these patients and what concentration of lidocaine to use.

This week is part 2 of our two episode series on steroid therapy with Dr. Gayle Fischer. Dr. Fischer is a professor of Dermatology at the University of Sydney in Australia, and has written books and has many years of research experience in the area of vulvar dermatology and lichen sclerosus (LS). In this episode, Dr. Selk and Dr. Fischer discuss steroid therapy in pregnancy, whether prescribed steroid strength depends on a patient's age, how often to follow-up with patients, natural remedies and how to advise patients about this, how to optimize steroid treatment, whether steroids can ever be stopped, and whether steroid treatment can prevent complications of LS.

In today's episode Dr. Selk interviews Dr. Jacob Bornstein, a professor of Obstetrics and Gynecology in Israel, past president of the ISSVD and chair of the terminology committee, with extensive publications in vulvar disease. Today we are covering vestibulectomies -- what a vestibulectomy is, the history behind it's development, indications, it's success rate in treating vulvodynia, and at what point to offer vestibulectomy. Other topics discussed include complications associated with vestibulectomy and the rate at which they occur, answers to questions commonly asked by patients (what will it look like? and will it prevent vaginal delivery?), how long to follow patients post-operatively, which patient populations are less likely to be cured, extensive versus minimal surgical techniques, and post-operative recovery.

In another episode with Dr. Melissa Mauskar, a dermatologist from UT Southwestern Medical Center in Dallas, Texas, her and Dr. Selk discuss pigmented vulvar lesions. Topics covered include types of vulvar pigmented lesions, mimickers of pigmented lesions, when to biopsy, vulvar melanoma, specific ways to biopsy melanomas, post-inflammatory hyperpigmentation, treatments, and symptoms associated with pigmented lesions.

Dr. Selk interviews Dr. Jennifer Bradford, who is a gynecologist in Sydney, Australia with an exclusive vulvovaginal practice and the co-author of the clinical handbook "The Vulva." This episode covers surgeries for scarring secondary to lichen planus and lichen sclerosus. Topics discussed include types of surgeries, pre-operative requirements, anesthetics, surgical techniques, who to operate on, treating vaginal agglutination in lichen planus, and post-operative management.

In her second feature on "The Vulva Diaries," Dr. Selk interviews Dr. Melissa Mauskar, a dermatologist at UT Southwestern Medial Center in Dallas, Texas, about issues that can occur with vulvar hair removal. Topics covered include hair removal methods, side effects from shaving, prevention of these side effects, reasons for vulvar hair removal, side effects from hair removal creams and waxing and prevention of these side effects, managing burns from waxing, laser hair removal, issues with permanent hair removal, how to approach providing patient education about vulvar hair removal, and vulvovaginal disease patients that should not engage in hair removal.

Dr. Selk interviews Dr. Mario Preti, a gynecologist and oncologist in Torino, Italy and the past President of the International Society for the Study of Vulvovaginal Disease (ISSVD), about vulvar cancer. Topics covered include prevalence, demographics, types of vulvar cancer, risk factors and causes, how vulvar cancer patients present, what is seen on physical exam, diagnosis, how to biopsy a suspicious lesion, treatment, impact of lymph node metastases, inguinal lymph node removal and sentinel node dissection, treating advanced vulvar cancer, when to recommend radiation therapy, prognosis, recurrence, treating recurrent disease, prevention of vulvar cancer, supportive care and the importance of patient awareness.

Dr. Selk interviews Dr. Sophie Bergeron, a professor of psychology at the University of Montreal, about the role of a psychologist in treating vulvovaginal disease patients. Topics covered include how psychologists can help vulvovaginal disease patients, what kind of therapy is used for these conditions, the evidence behind CBT for vulvar pain disorders, strategies for emphasizing the importance of seeing a psychologist to patients, how to find a good therapist, different kinds of sex therapists, if patients require referrals, average cost of treatment, average number of sessions required, and couples therapy.

Dr. Selk interviews Dr. Debra Birenbaum, an obstetrician-gynecologist at Dartmouth-Hitchcock Medical Center in New Hampshire, about genital warts. Topics covered include prevalence, diagnosis, treatment options and specific treatment methods, treating resistant bulky disease, when to biopsy, vaccination, treating warts in pregnancy, and treating immunocompromised patients.

Dr. Selk interviews Dr. Mark Yudin, an obstetrician gynecologist at St. Michael's Hospital in Toronto with a combined clinical and research fellowship in Reproductive Infectious Diseases, about genital herpes. Topics covered include prevalence of genital herpes, causes of herpes, typical presentations, how to test for it, treatment options, tips for counselling patients, long term course of infection, and suppression in pregnancy.

Dr. Selk interviews Dr. Tania Day, a gynecologist in Newcastle, Australia with a PhD in the pathology of lichen planus, about vulvovaginal pathology. Discussion topics include where to take biopsies and what areas to avoid, when to use different biopsy types, what to write on pathology requisitions, advantages of reading pathology descriptions, interpreting pathology patterns (psoriasiform, spongiotic, lichenoid, etc.), and information on resources to learn more. Dr. Day also answers questions including do steroids mask diagnoses/should clinicians hold off on steroids before taking a biopsy, why do lichen planus biopsies often return a non-specific result, what to do when your biopsy result doesn't make sense, and are there specialized vulvar pathologists?

Dr. Selk interviews Dr. EJ Mayeaux, the chairman of the Department of Family and Preventative Medicine and professor of Obstetrics and Gynecology at the University of South Carolina, about lichen simplex chronicus (LSC). Topics covered include the definition of LSC, how common LSC is, diagnosis, what advice to give to patients, treatment options, counselling around steroid use, medications for controlling itch, recurrence rate, and the importance of motivating patients for cure.