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.

In this week's episode Dr. Selk interviews Dr. Claire Danby, who is an obstetrician gynecologist at Maine Medical Center with a dedicated vulvovaginal clinic and a clinical assistant professor at Tufts University. Today they discuss desquamative inflammatory vaginitis (DIV). Topics covered include the definition of DIV, presentation, diagnostic criteria, etiology, demographics, prevalence, a systematic approach to diagnosis, treatment, treatment changes based on menopausal status, other conditions that get confused with DIV, and cure rate of DIV.

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 Dr. Selk interviews Dr. Jacob Bornstein in his second episode with "The Vulva Diaries"! Dr. Bornstein is 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. In this episode they discuss the terminology of vulvodynia. Topics covered include history behind the terminology of vulvodynia, potential etiologies of vulvodynia, the process behind updating terminology, key elements that factor into determining the terminology of vulvodynia, importance of ascertaining the main associated cause of a patient's vulvodynia, evidence behind treatments for vulvodynia, and the story of the emergence of vulvodynia into the research spotlight.

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.

Dr. Selk interviews Dr. Gayle Fischer in part 1 of our 2 episode series on steroid therapy. 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). Topics covered include the importance of using long-term steroids in certain vulvar conditions, how to respond to patient fears about steroids, studies assessing side effects of steroid use in these conditions, matching the strength of the steroid to the severity of disease, providing instructions to patients, importance of raising awareness about vulvar diseases, long-term steroid use in pediatric vulvar disease, and psychosocial implications of pediatric 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.

Dr. Selk interviews Dr. Gayle Fischer, a dermatologist at the University of Sydney in Australia and an expert in lichen sclerosus (LS), about new LS treatments. Topics covered include steroid treatment and why patients seek different treatments, new ancillary treatments and evidence behind them, patient counselling tips, post-procedural steroid use, dangers of calcineurin inhibitors in LS, and benefits of topical steroid treatment.

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.

In this week's episode Dr. Selk chats again with Dr. Jennifer Bradford, a gynecologist in Sydney, Australia with a tertiary care practice in vulvovaginal disease and co-author of “The Vulva” handbook. In this second episode covering lichen sclerosus and lichen planus with Dr. Bradford, they discuss how pregnancy can affect these conditions. Topics discussed include how lichen sclerosus (LS) and lichen planus (LP) symptoms change over the course of pregnancy and post-partum, LS and LP treatments during pregnancy, vaginal delivery with LS or LP, managing post-partum LS flares, topical steroid safety in pregnancy (and tips on how to counsel patients about this), elective C-sections, potential effect of breastfeeding on post-partum flares, and tips for motivating patients to improve treatment compliance post-partum.

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.

Dr. Selk interviews Dr. Sofia Torres, a gynecologist in Buenos Aires, Argentina, about cosmetic gynecology. Topics covered include types of cosmetic gynecologic procedures (surgical and non-surgical), why they've become more popular, who offers these procedures, evaluating patient motivations for undergoing these procedures, resources for patient education, patient counselling recommendations, assessing for organic anatomic issues, post-operative complications, and laser procedures.

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. Michelle Jacobson, a gynecologist in Toronto, about graft versus host disease (GVHD). Topics covered include the definition of GVHD, counselling of stem cell transplant patients, assessing for genital GVHD, patient presentation, detecting GVHD in the context of menopause, physical features of genital GVHD, when to treat with surgery, recurrence risk, medical therapies and other treatments, vaginal creams versus ointments, treating post-menopausal women with vaginal steroids, the role of biopsy in diagnosis, and important information to communicate to your pathologist.

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.

This is our first patient interview episode! In this episode Dr. Selk interviews Clare Baumhauer, who is a patient with lichen sclerosus and vulvar cancer, a patient advocate for these conditions, and the co-founder of the UK Vulvar Cancer Awareness Group. Topics covered include Clare's patient journey, including her long road to diagnosis, reasons for lack of patient and healthcare provider awareness about vulvovaginal diseases, difficulties with finding knowledgable practitioners, the story behind her amazing campaign, importance of correcting misinformation about steroid use for treating lichen sclerosus, advice for vulvovaginal disease patients, messages to healthcare providers about lichen sclerosus and vulvar cancer, and the importance of patient support groups.

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. Melissa Mauskar, a dermatologist at UT Southwestern Medical Center in Dallas Texas, about lichen planus. Topics covered include the definition of lichen planus, the different forms of lichen planus, prevalence, typical presentation, what to look for on exam, when and how to biopsy, and steps to take after you get a non-specific biopsy result. They also discuss different treatments, depending on whether the patient has localized vulvar disease or disease in different areas of the body, treating the patient that's not getting better, which systemic therapies work best, how to treat patients with vaginal involvement, use of dilators, treating post-menopausal patients on topical estrogen therapy, which topical steroids to use, counselling patients on steroid application, and the impact of lichen planus on patients' quality of life.

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.

In Dr. Kristen Stewart's second episode, she and Dr. Selk discuss hidradenitis suppurativa (HS). Dr. Stewart is a dermatologist in Jacksonville, Florida. Topics covered include prevalence, diagnosis (and why it takes so long for patients to get diagnosed with this condition), clinical presentation, common symptoms and patient complaints, causes of HS, treatments (including lifestyle modifications, medical treatments and surgery), staging of HS, patient support, comorbidities, and differentiating between HS and cutaneous Crohn's disease.

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. Lynne Margesson, a dermatologist at Dartmouth, about vulvar ulcers. Discussion topics include common causes of ulcers (infectious and non-infectious), syphilis ulcers, questions to ask on history, Behcet's disease, aphthous ulcers (simple and complex), vulvar manifestations of Crohn's disease, when to biopsy, treatment, how to treat recurrences, managing chronic recurrent aphthous ulcers, managing dysuria, and ulcers associated with vulvar tumors.

Dr. Selk interviews Dr. Jill Allbritton, a dermatologist and dermatopathologist at the University of Maryland, and an expert in vulvar diseases. In this episode they discuss high grade squamous intraepithelial lesions (HSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). Topics covered include the definition of HSIL and dVIN, the symptoms and appearance of HSIL lesions, the presentation of dVIN and when to biopsy, diagnosis of HSIL and dVIN, the varying HSIL and dVIN treatments depending on the patient and lesion, recurrence rates, Bowen's versus HSIL on pathology, and patient follow up recommendations.

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. Mary Lou Baxter, a dermatologist and the co-director of the gynaecology-dermatology clinic at the Queen Elizabeth II Health Sciences Centre in Halifax, about a variety of vulvovaginal conditions causing itch. The conditions discussed include psoriasis on the vulva (how it presents, incidence, diagnosis, and treatment) and vulvar eczema (how it presents, diagnosis, common triggering irritants and allergens, when to use patch testing, and how to treat contact dermatitis).

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.

In this episode covering vulvodynia, Dr. Selk interviews Dr. Elizabeth Stewart, the co-founder and Director Emerita of the Vulvovaginal Service at Harvard Vanguard Medical Associates, Atrius Health in Boston, the author of "The V Book", and co-creator of the educational website vulvovaginaldisorders.com. Topics discussed include the definition of vulvodynia, known causes of vulvodynia, what questions to ask when patients present with pain, how to diagnose vulvodynia, how to counsel patients, treatment options, helpful resources for patients, frequency of follow-up, and the probability of complete resolution of symptoms.

Dr. Selk interviews Dr. Leslie Sadownik for part two of our lichen sclerosus talks. Dr. Sadownik is a gynecologist and the director of The BC Centre for Vulvar Health in Vancouver. This is an advanced talk and covers what to do when the patient is not getting better, how to treat patients with pain that is not improving, new lichen sclerosus treatments other than steroids, how to decide who to operate on, post-surgery treatment and counselling, re-operating with recurrence and how often to see patients once their disease is stable.

Dr. Selk interviews Dr. Leslie Sadownik, a gynecologist from Vancouver and the director of The BC Centre for Vulvar Health, about lichen sclerosus. Topics discussed include common symptoms, demographics, how lichen sclerosus is diagnosed, differentiating between lichen sclerosus and lichen planus, indications for biopsy, treatment, and counselling around topical steroid use.

Dr. Selk interviews Dr. Luann Racher, a gynecologist from the University of Arkansas for Medical Sciences, about vulvar cysts. Topics covered include what kinds of cysts can be found on the vulva, how to treat the different cyst types (Gartner's duct cysts, Bartholin gland cysts, Skene's duct cysts, and sebaceous cysts), risk of recurrence, treatment for infected cysts, and when to biopsy a cyst.

Dr. Selk interviews Dr. Marc Steben, a family physician and sexual health expert in Montreal, Quebec, Canada, about recurrent and persistent vaginitis. Topics discussed include defining recurrent and persistent vaginitis, how to assess these patients, causes of persistent symptoms, treatments, lab monitoring for patients on long-term prophylaxis, and advice for managing vaginitis patients within primary care.

Dr. Selk interviews Jessica Nargi, a pelvic physiotherapist in Toronto, Canada, about the utility of pelvic physiotherapy for vulvovaginal disease patients. Topics discussed include what pelvic physiotherapy involves (and the difference between pelvic and general physiotherapists), components of the initial pelvic physiotherapeutic assessment (including which questionnaires are used), which conditions can be treated by pelvic physiotherapists, importance of the biopsychosocial approach, treatments used, the benefit of physiotherapy versus at home/internet treatments, number of treatment sessions required, cost per session, and resources for finding physiotherapists.

Dr. Selk interviews Dr. Terri Vanderlinde, a gynecologist and sexual counselling expert in New Hampshire, on how to counsel vulvovaginal disease patients about their sexual health. Topics covered include how to address and manage sexual health concerns in vulvovaginal disease patients, how to approach the topic of sex issues with these patients, accessibility of sex counsellors and therapists, cost of sex counselling, an approach to body image issues due to vulvar scarring, advice for increasing pleasure, scarring over the clitoris, and online resources for patients.  

Dr. Selk interviews Dr. Yolanda Kirkham, an obstetrician and gynecologist with a clinical fellowship in pediatric and adolescent gynecology at Women's College Hospital and St. Joseph's Health Centre in Toronto, about pediatric vulvovaginal disease. Topics discussed include common vulvar issues in young girls and their causes, taking a culture in children, how to examine, common foreign bodies, causes of discharge in children, pre-pubertal peaks of lichen sclerosus, labial agglutination, pediatric genital ulcers, and where to find further resources.

Dr. Selk interviews Dr. Michelle Jacobson, a menopause expert gynaecologist in Toronto, about treating vulvovaginal issues during and after menopause. Topics covered include changes in the vulva and vagina in menopause, counselling around local and systemic estrogen therapy (safety/when to use systemic therapy/combining therapies/choosing between vaginal estrogens/DHEA/combing estrogens and topical steroids), non-hormonal over-the-counter treatments for menopausal symptoms, and sexual counselling in post-menopausal patients.

Dr. Selk chats with Julia Dmytryshyn, a medical student at the University of Toronto, and provides an introduction to vulvar diseases. Topics include basic principles with vulvar conditions, approach to diagnosis, how to do a biopsy, general advice for vulvar concerns (advice about using drug store products), counselling around topical steroid use, and patient resource recommendations.

Dr. Selk chats with Dr. Nancy Phillips, a gynaecologist and director of the vulvovaginal clinic at Rutgers in New Jersey, about bacterial vaginosis (BV). Topics discussed include diagnosis of BV, treatments, counselling around metronidazole use, treating recurrences and preventative strategies.

Dr. Selk interviews Dr. Caroline Mitchell, a gynaecologist and Director of the Vulvovaginal Health Clinic at Massachusetts General Hospital in Boston, about acute and recurrent yeast infections. Topics covered include diagnosis, definition of recurrent yeast, treatment, non-albicans yeast, steps in treating recurrent infection and modifiable risk factors for recurrent yeast (as well as dispelling myths about common prevention strategies).

Dr. Amanda Selk interviews Dr. Kristen Stewart, a dermatologist in Jacksonville, Florida, about vulvovaginal itch. Topics covered include dermatology's role in vulvovaginal health, common causes of vulvovaginal itch, what questions to ask the patient and what to look for on physical exam, common vulvar irritants, treatment of vulvovaginal itch, and how to deal with recurrent itch.