There are a variety of gynecologic problems that involves the vulva and adjacent parts. Several vulvar conditions occur most commonly in postmenopausal women. Symptoms are primarily itching and vulvar soreness, in addition to dyspareunia. Vulvar lesions include vulvar ulcers, urethral lesions, squamous hyperplasia, lichen sclerosus, and mixed dystrophy, to name a few. Gynecology microscopes have helped gynecologists in differentiating and diagnosing each gynecologic problem.

Vulvar Ulcers

A number of sexually transmissible infections can cause vulvar ulcers, including herpes simplex virus, syphilis, lymphogranuloma venereum, and.granuloma inguinale. Crohn’s disease can include vulvar involvement with abscesses, fistulae, sinus tracts, fenestrations, and other scarring. Although medical treatment with systemic steroids: other systemic agents are the mainstay of therapy, surgical therapy of both intestinal and vulvar disease may be required.

Behcet’s disease is characterized by genital and oral ulcerations with ocular inflarnmation. The cause and the most effective therapy are not well established even with the use of gynecology microscopes.

Lichen planus also causes oral and genital ulcerations. When seen under gynecology microscopes, there is desquamal vaginitis with erosion of the vestibule. Gynecologic treatment is based on the use of both topical and systemic steroids. Plasma cell mucositis appears as erosions in the vulvar area, particularly the vestibule. Biopsy with the use of gynecology microscopes is essential in making the diagnosis.

In the past, numerous terms have been used to describe disorders of vulvar epithelial growth that produce a number of nonspecific gross changes. These terms have included leukoplakia, lichen sclerosus et atrophicus, atrophic and hyperplastic vulvitis, and krauro¬sis vulvae. The malignant potential of the vulvar dystrophies is less than 5%; at particular risk is the patient with cellular atypia on initial biopsy. The International Society for the Study of Vulvar-Diseases (ISSVD) has recommended a classification of vulvar dystro¬phies.

Urethral lesions

Vulvar lesions that may be seen in other age groups, but that occur more commonly among older women, include urethral caruncles and prolapse of the urethral mucosa. Both condi¬tions can be treated with topical or systemic estrogen cream. Various vulvar skin lesions, including seborrheic keratoses and “cherry” hemangiomas (senile hemangiomas), occur more commonly on aging skin.

Squamous Hyperplasia

Squamous hyperplasia is seem most often in postmenopausal women but may occur during the reproductive years. Pruritus is the most common symp¬tom. The lesion appears thickened and hyperkeratotic, and there may be excoriation. Squa¬mous hyperplasia tends to be discrete but may be symmetrical and multiple. Examination (with the use of gynecology microscope) and biopsies are necessary to make the diagnosis and to evaluate the presence of atypia and exclude malig¬nancy.

The treatment is local application of a fluorinated corticosteroid ointment three times a day for 6 weeks. Typically, the lesion totally regresses. If a new lesion recurs, repeat biopsy should be performed and an additional 6 weeks of treatment with topical steroids should be given.

Lichen Sclerosus

Lichen sclerosus is the most common white lesion of the vulva. Lichen sclerosus can occur at any age, although it is most common among postmenopausal women. The symptoms are pruritus, dyspareunia, and burning. Lichen sclerosus characteristically presents with decreased subcutaneous fat such that the vulva is atrophic, with small or absent labia minora, thin labia majora, and so times phimosis of the prepuce. The surface is pale with a shiny, crinkled pattern, often fissures and excoriation. The lesion tends to be symmetrical and often extends to the perineal and perianal areas. The diagnosis is confirmed by biopsy with the use of a microscope. Invasive cancer is only rarely associated with lichen sclerosus.

The treatment is with 2% testosterone cream in a petrolatum base applied twice daily for 3 weeks and then once daily for 3 weeks. A maintenance treatment of once daily or once every other day is continued, depending on the response and the persistence of the symptoms. The patient must be informed that testosterone can produce masculinizing side effects. Treatment must be continued indefinitely, because the testosterone allows the patient to live with the disease instead of curing the disease. Alternatively, 0.05% clobetasol, potent steroid, can also be used, and approximately 80% of patients have a satisfactory response. Superficial vulvectomy can be used in severe cases or in those who refractory to medication. Recurrences are common after surgical treatment

Mixed Dystrophy

Mixed dystrophy consists of varying proportions of hypoplastic and hyperplastic tissues, and accounts for about 20% of vulvar dystrophies. Atypia occurs more frequently in mixed dystrophy than in pure hyperplastic dystrophies. The symptoms are burning, pruritus, and dyspareunia. The lesion appears as keratinized, white epithelium associated with patches of pale, thin, shiny, wrinkled epithelium. The diagnosis can be done using gynecology microscopes and  biopsy must be done. Multiple biopsies are necessary to exclude areas of focal atypia.

The treatment is fluorinated corticosteroid ointment three times daily for. 6-8 weeks followed by 2% testosterone ointment three times daily for 6-8 weeks. Thereafter, testos¬terone ointment should be used indefinitely, usually every other day. Areas of severe atypia may be best treated by local excision.