Vulvovaginal Health is Skin Health

A note on patient stories: The patient cases in this piece are composites drawn from my clinical practice. Identifying details have been changed to protect privacy. The clinical patterns are real; the individuals are not.

My last slide was a prescription.

Not a new injectable. Not a first-in-class biologic. Not a regenerative medicine breakthrough. A prescription for vaginal estradiol cream, with drug name, strength, sig, quantity, and refills, and one line underneath:

Because vulvovaginal health is skin health.

I was standing on stage at the SCALE dermatology conference in Nashville on Saturday, in a room full of academic giants, with five minutes and twelve slides to cover evidence-based strategies for perimenopausal skin. I spent the last of those minutes teaching dermatologists how to write a prescription; almost none of them learned to write in residency. The older generation who told menopausal patients to rub Premarin on their faces has retired. The rest of us were never really taught.

So I taught it. In five minutes, between talks on toxins and regenerative medicine, I stood up and said something I have come to believe deeply: this is skin too, and it belongs to us.

I want to describe two kinds of patients I see in the clinic. Not because either case is rare, but because both are common, and most women never know they belong to the pattern.

The first is the woman suffering in silence.

She has been uncomfortable for years before she brings it up. Not weeks. Years. Sometimes it’s itching, other times burning. She has a standing prescription for a yeast infection because that’s what she has been told she needs – it doesn’t ever help, but she wonders if she keeps doing something wrong to reinfect herself. She has adjusted how she sits, what she wears, what she uses, and whether she can focus through a workday. She has not told her primary care doctor, has not told her partner, has not told anyone, because she is embarrassed, and because somewhere along the way she quietly decided that this was just what her body was now.

When she finally comes in, it is almost always because the misery has outgrown the shame. That is a sentence I want every woman reading this to sit with for a moment. The misery had to outgrow the shame. That is the bar we have set for women in this country, and it is far too high.

Her exam takes about four minutes. More often than not, two things are happening at once: a contact or irritant dermatitis from something she has been using for years, and genitourinary syndrome of menopause underneath it. One is an irritant she needs to stop. The other is estrogen-deficient skin that needs estrogen back.

Allergen avoidance. Vaginal estradiol cream. Years of suffering were resolved across a handful of visits.

I think about these patients often. Not because their cases are complicated. They aren’t. I think about them because of how long they carry it. How easily it could have gone on for another year, or three more years, or indefinitely. How many women are sitting in that same silence right now, having decided that itching, dryness, burning, painful intimacy, recurrent UTIs, or the slow erosion of their sex life is just the new normal?

It isn’t. Most of it is treatable. A lot of it is treatable by a dermatologist.

The second kind of patient is the one a dermatologist might miss.

She comes in for a routine skin check. Somewhere in the visit, she mentions, almost in passing, that she has noticed something different in an area she would not have asked me to examine without prompting. A new spot. A patch of skin that has changed color. A texture that wasn’t there a year ago. She had her annual gynecology visit not long before. They did not see it. She did. She brings it up because she has been wondering.

And sometimes what she has been wondering about is serious. Vulvar melanoma exists. Vulvar squamous cell carcinoma exists. Lichen sclerosus exists and carries a non-trivial cancer risk if it is not treated. None of these is common. All of them are findable by a dermatologist, on an exam that takes a few extra minutes.

These cases have left me with a question I have not been able to put down: which specialty owns the vulvovaginal area?

The honest answer is that dermatology has to. Not exclusively. Our gynecology and urology colleagues are essential partners. But we cannot keep assuming someone else is examining this skin with the expertise that defines our specialty. The vulva is skin. The mucosa is skin. Melanoma grows there. Lichen sclerosus presents there. Contact dermatitis erupts there. Genitourinary syndrome of menopause manifests there. And we are the doctors of skin.

The area is small, and women are often silent. We can’t assume that lack of concern means absence of a problem. Sometimes it just means a woman has been waiting years for her misery to outgrow her shame. Every time we skip that exam and assume someone else has it covered, we miss a chance to change a woman’s life. Sometimes to save it. Often, just to give it back to her.

So here is what I would ask.

If you are a dermatologist, examine this area. Ask the question. Learn the prescription. (The full Rx is below.) If it is outside your comfort zone, that is a place to start learning, not a reason to send her elsewhere.

If you are a patient, make sure someone is checking this area, and make sure that someone is comfortable managing what they find. That might be your dermatologist. It might be your gynecologist. It might be a urogynecologist or a menopause specialist. The point is not which specialty. The point is that someone is doing it, and that you are not waiting years to bring up what you have noticed.

The most important slide I showed on that stage was a prescription. If one dermatologist took it home and started writing it, the flight was worth it. The time away from my family was worth it. Standing in a room of giants with my voice slightly shaking was worth it. Because somewhere out there is a woman who has been quietly itching, and a woman wondering about a spot she hasn’t mentioned, and they both deserve a doctor who is ready for them.

The Prescription (for my dermatology colleagues)

Vaginal estradiol cream is one of the safest, most effective tools we have for genitourinary syndrome of menopause. It is local therapy, with minimal systemic absorption at standard dosing, and it is appropriate for the vast majority of perimenopausal and menopausal women, including many with a history of breast cancer, in coordination with their oncology team.

A standard starting prescription:

Estradiol vaginal cream 0.01%

Sig: Apply 1 g to the vulva and distal vagina nightly for 2 weeks, then 2–3 times per week for maintenance.

Quantity: 42.5 g tube

Refills: 3

Counseling pearls I give every patient:

• Apply with a clean fingertip to the vulva, vestibule, and just inside the vaginal opening. The applicator that comes in the box is optional. Most of the symptomatic tissue is external.

• It can take 8–12 weeks to feel the full effect. Stick with it.

• This is not the same as systemic hormone therapy. It is treating skin.

If you are not comfortable managing this prescription, that is a reasonable place to start learning, not a reason to send her away. The Menopause Society (menopause.org) has excellent clinician resources, and I’ll be writing more about dosing nuances, alternative formulations (estradiol tablets, rings, DHEA inserts), and the breast cancer conversation in future posts.

If you are a patient reading this, feel free to bring this post to your appointment. That is exactly what it is for.