Vulvar itching in perimenopause: the condition that must be examined

Why this one needs looking at

Most symptoms in this collection can reasonably be approached with information first. Vulvar itching is different, because the conditions causing it look different from each other and cannot be told apart by description.

The common cause is benign and treatable. One of the less common causes causes permanent scarring if untreated and carries a small risk of malignancy. Both itch.

Repeated courses of over-the-counter thrush treatment without an examination is the pattern that delays the diagnosis, and it is extremely common.

The usual cause

As oestrogen falls, vulvar and vaginal tissue thins, dries and loses elasticity, and the skin barrier weakens. Thin, dry skin itches, and scratching damages it further, establishing a cycle.

The vaginal pH also rises, shifting the microbial balance. A practical consequence worth knowing: thrush becomes less common after menopause, not more, so persistent itching being treated as thrush is often being treated as the wrong thing.

This cause responds well to local vaginal oestrogen, along with emollient use and avoiding soap on the vulva.

Lichen sclerosus, which is why the examination matters

Lichen sclerosus is a chronic inflammatory skin condition that disproportionately affects postmenopausal women. It causes intense itching, often worst at night, along with white, thinned, crinkled or shiny skin.

Untreated it causes progressive scarring: loss of the labia minora, narrowing of the vaginal opening, and burying of the clitoris. Those changes are permanent.

It also carries a small increased risk of vulvar squamous cell carcinoma, which is why long-term follow-up is part of management.

It is treated effectively with potent topical steroids, and this is the case where the intuition that steroids should be used sparingly on delicate skin is wrong: under-treatment is the usual problem and allows the scarring to progress.

What else causes it

• Contact dermatitis from soaps, wipes, laundry detergent, panty liners or fragranced products — very common and entirely reversible
• Eczema or psoriasis affecting the vulva
• Thrush, which does still occur, particularly with diabetes or after antibiotics
• Bacterial vaginosis, more often causing odour and discharge than itching
• Lichen planus, which can affect the vulva and mouth together
• Vulvar intraepithelial neoplasia or vulvar cancer, which is why any persistent lump, ulcer or colour change needs examining
• Undiagnosed diabetes, which predisposes to recurrent thrush

When to see someone

See a clinician for vulvar itching that has lasted more than a few weeks or has not responded to one course of treatment, and ask to be examined rather than treated on description.

Seek prompt assessment for white or thickened skin, any lump, ulcer or sore that does not heal, changes in vulvar shape, bleeding, or pain. Stop using soap, wipes and fragranced products on the vulva in the meantime, which alone resolves a meaningful share of cases.