Transcription:
Gynecology: Complex Vulvar and Vaginal Diseases

Melanie:  Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we examine complex vulvar and vaginal diseases.

Joining me in this panel are Dr. Lauren Streicher, she's a Clinical Professor of Obstetrics and Gynecology at Northwestern Medicine, and Dr. Rajal Patel, she's an Instructor of Obstetrics and Gynecology at Northwestern Medicine. Doctors, I'm so glad to have you join us today. And Dr. Streicher, I'd like to start with you. Tell us about the motivation for you to start a vulvar program and how did this come about?

Dr Lauren Streicher: Vulvar conditions represents a huge unmet need. And it is an area in which quite frankly, many, if not most gynecologists receive only minimal training. And we were seeing so many women in our menopause and sexual medicine programs with vulvar conditions that had either been inadequately treated or not treated at all. And we realized that we needed a designated program.

Melanie: So then how do women find their way to your program, Dr. Streicher? Are they referred by their physicians? Can they self-refer? Tell us about that.

Dr Lauren Streicher: Well, at this point, most women are self-referred. But our goal is to change that, because quite frankly, most physicians don't even know that we exist. Most patients find their way to us because they're having bothersome symptoms that someone else wasn't able to help them with like chronic itching, pain, or maybe they were given a diagnosis such as vulvar intraepithelial neoplasia and they are looking for expert advice, expert treatment. So, yeah, right now, they're finding their way to us on their own.

Melanie: What an important unmet need. So Dr. Patel, given that most gynecologists get minimal training in vulvar conditions, tell us about the training and experiences that informed your expertise and what additional training is really recommended and indeed important.

Dr Rajal Patel: Sure. I completed a fellowship in vulvovaginal disorders at the University of Michigan under internationally renowned vulvologist. Dr. Hope Haefner. Not only was the center at the University of Michigan a referral center for difficult cases all over the world, but also it was one of the few places in the country where super specialized surgical treatment was performed for these complex cases.

Melanie: Well then Dr. Patel, walk us through how you conduct a vulvar examine and what makes that different than a regular Pap smear exam that many providers conduct.

Dr Rajal Patel: This exam very different in that it's extremely thorough. I am looking at the skin, the lymph nodes. I'm looking at the prepuce, which is the hood of the clitoris and whether the clitoris is visible or not. I'm inspecting the interlabial sulci, the space between the labia minora and the labia majora. I'm looking at the vestibule, the urethra. I'm looking at the introitus and the caliber. I'm looking at the perineum. the anus. And instead of using the speculum first, we actually do a single-digit exam to examine all the different muscles of the pelvic floor and then use the speculum, because a lot of patients have severe pain and once you put the speculum in, their hypertonic pelvic floor kicks in and it's impossible to do a thorough exam.

Dr Lauren Streicher: And I do want to add, something that's unique about our exam is that we include the patient in the exam, which is something that most doctors don't do. We give the patient a mirror. And as we are examining her vulva and talking about all these very specific areas of not only the skin and the tissues, but the structures, we point them out to the patient because unlike men that have a pretty good idea of what their external genitalia looks like, most women really don't. And while they might be a little reluctant, they really appreciate the tutorial.

Dr Rajal Patel: That's a very important point, yes. And we also, with their permission, take photographs for photo documentation to see how their disease is doing over time.

Dr Lauren Streicher: And on the topic of photographs, I want to mention that, yes, of course, we get their permission, but we also have a designated clinic phone with a HIPAA compliant app that automatically populates the patient's chart. So it's not floating out there on the internet. And also to make the patient more comfortable, we put these photos in a place on their electronic medical record, where we know where to find them, but other clinicians, who maybe have nothing to do with knowing about their vulva, are not going to be able to easily access them.

Melanie: That's amazing. I'm so glad you do that for women, because it can be uncomfortable. And Dr. Streicher, you mentioned that you give them a mirror. For other providers and they're referring their patients to your program, can you tell them how comfortable-- you mentioned that some women are hesitant at first. But women, you know, we're not always that comfortable doing this sort of thing. How do you ease that?

Dr Lauren Streicher: Well, that's right. Because the problem is that many women are taught that their genitals are a taboo area, that this is something they shouldn't touch. They shouldn't look at. Certainly, they don't even use proper terminology. So their initial reaction is, "What? Mirror? No, thank you." Or I hand them the mirror, which is a very long handled mirror so that they can easily see and the first thing they always do is check their face. It's just automatic. They hold it up to their face. And so, once we say to them, "No, no, no. This is just what we do here." And it is the rare, rare woman who doesn't agree. And we're so matter of fact about it, as Dr. Patel said. We basically go through in a very specific order and we start at the top of the clitoris and the clitoral hood.

And while they might be a little bit off-put, we have never ever had anyone say anything, but "Wow. I didn't know that's where that was located or what that was." And the other thing also is, I just want to point out, most women assume that they're abnormal. They just do. They think they don't look like other women. And the most important thing that we say as we examine the woman part by part is "This is normal and healthy. This is normal and healthy," and they're very grateful too and reassured. And if there's something that's not normal and healthy, believe me, they were a little bit concerned about that already and are glad that we noticed it.

Melanie: What great points. So Dr. Patel, lichen sclerosis is usually diagnosed and managed by a general gynecologist and even sometimes a dermatologist. When should those cases be referred to you? And tell us a little bit about management and what's involved.

Dr Rajal Patel: Sure. So even extremely stable lichen sclerosus requires maintenance steroid treatment in order to keep the cancer away, which is what a lot of people don't realize. And a lot of times we have patients referred to us with a diagnosis of lichen sclerosis. But when I do the biopsy, we may get back a precancer or a completely different type of skin disorder. So I think it's very important that these patients follow with somebody who is very familiar with lichen sclerosis and other vulvar dermatosis.

Dr Lauren Streicher: The other thing I'd like to add is a lot of general gynecologist, while they may have a familiarity, they just don't have the time. And one of the things that's unique about our program is that because we are so targeted, we can spend the time to answer the patient's questions, to talk to them, to give them written material so that they walk out feeling that they have really been educated about their condition, such as lichen sclerosis, in addition to knowing that they have received expert recommendations.

Melanie: What a great point. So Dr. Streicher, expand a little on other conditions and common conditions that you see at the center.

Dr Lauren Streicher: Well, because we have a menopause center, we see a lot of vulvar and vaginal atrophy as a consequence of genitourinary syndrome of menopause. And I just want to point out that many gynecologists are really good. They're really good at treating this. They treat vaginal dryness and atrophy all the time, but we see a lot of the treatment failures.

And the reason for that is that they often treat the vagina, but not the vestibule and the vulva, which we consider separately. So as an example, they may prescribe an estradiol tablet insert and send the patient on her way. And then she continues to have dyspareunia because they did not treat the vestibule separately and is still atrophic. And as I always say, "It doesn't matter how nice the room is if you can't get through the door." So we treat and regard separately the opening to the vagina and the vagina itself. Bottom line, patients find their way to us because the treatment they have been given just simply isn't working.

Dr Rajal Patel: I'd also like to add that, regardless of why the patient is having pain, as a result of the pain, they usually have a hypertonic pelvic floor. And what's unique to our center is that we have pelvic floor physical therapists right there in the same space that we collaborate with. So most GYN offices don't have this kind of access.

Dr Lauren Streicher: The other thing our program has that most other programs do not in addition to pelvic floor physical therapist as part of our collaborative team, we have sex therapists. And I can tell you that these women who have painful sex, even if they don't think they're going to benefit from individual a couples therapy about the psychosocial consequences, really benefit from access to one of our certified sex therapist who are able to meet with our patients either as individuals or if they're part of a couple.

Melanie: Well then Dr. Patel, you're a vulvar surgeon as well. Tell us about some of the conditions that may require surgery. Give us a quick rundown of other conditions that you routinely see and why surgery is sometimes recommended.

Dr Rajal Patel: Sure. So Bartholin's duct cyst, for example, that are refractory to medical treatment; pre-cancer of the vulva, whether it's from HPV or if it's a result of lichen sclerosis, something called differentiated VIN; condyloma or warts; hymenal or labial abnormalities that impact a woman's sex life; Paget's disease; adhesions from lichen sclerosis that impede urination; lichen planus that causes agglutination of the vagina making intercourse impossible; and then hydradenitis suppurativa, which sometimes requires surgical excision in extreme cases.

Melanie: What an interesting profession you are both in and what an exciting time to be in your profession. So Dr. Streicher, starting the last word to you, give us some information that would be useful for other physicians to pass onto their patients about vulvar health and why you feel this is maybe an unmet need that you are now meeting and why it's so important that they are informed.

Dr Lauren Streicher: Well, first of all, patients need to be introduced to their vulvas. They need to know that the vulva is not the same as the vagina and to be familiar with their normal anatomy, but also patients need to be informed that commercial vulvar hygiene products, so-called hygiene products, are not only unnecessary, but they're highly problematic.

And this is particularly the case in young women who think their genitals are supposed to smell like an English garden or that they're not cleaning this. They use a purfumed vulvar wash. And doctors assume that women know this, but they're being sold all of this stuff, which is causing a lot of problems. In addition, our post-menopause patients who have particularly thin atrophic tissue, which is very vulnerable, they need to be told to stay away from these products. Even the wrong lubricant if it has a high osmolality, can cause further atrophy, mucosal inflammation, tissue breakdown and big problems.

So I look at the physician's role is to educate their patients on not only what's normal and what's abnormal, but how to keep things healthy.

Melanie: Such an important point. And Dr. Patel, last word to you, what would you like other providers to take away from the program at Northwestern Medicine, the importance of referral and helping their patients to feel more comfortable about going to a new program?

Dr Rajal Patel: So I'd like them to know that I'm here to help. We're very specialized. I have the time, the training, the expertise, and I'm always happy to see their patients.

Dr Lauren Streicher: And I want to add something that's very important and that's we do not do general gynecology. You know, a lot of doctors are reluctant to refer because they think they're going to lose the patient. Nothing could be further than the truth. As Dr. Patel said, we are targeted, we are specialized. If someone says, "Will you do my Pap test? Will you do my breast exam?" We say, "No." You're going to go back to your general gynecologists. We're going to communicate with your gynecologist. And very often, we will see them for an initial consultation and then give the referring doctor the tools that they can carry on what we have started.

Dr Rajal Patel: Absolutely.

Melanie: What a great program. Doctors, thank you so much for joining us, sharing your expertise and really telling us about the program at Northwestern Medicine. To refer your patient, please visit our website at sexmedmenopause.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.