Dryness, dyspareunia, dysuria and urgency in a postmenopausal woman point so naturally at hypo-oestrogenism that the examination often becomes a formality. Vulvar dermatoses share every one of those symptoms, and several of them scar.
The discriminator is morphology and distribution, not symptom. Genitourinary syndrome of menopause is diffuse: pallor, thinning, loss of rugae, mucosal atrophy across the vestibule and vagina. Lichen sclerosus is patterned — white, sclerotic, often figure-of-eight around vulva and perianal skin, with resorption of the labia minora, burying of the clitoris and introital narrowing. Lichen planus favours the vestibule and the vagina with erosions and a violaceous edge, and can obliterate the vagina. Any fixed plaque, ulcer or area that fails to settle needs a biopsy, not a second course of oestrogen.
The cost of getting this wrong is not a delayed symptom cure — it is architecture. Scarring from untreated lichen sclerosus does not reverse when the diagnosis is finally made, and the condition carries a vulvar squamous cancer risk that surveillance is meant to catch. A topical oestrogen trial is reasonable; a topical oestrogen trial with no examination and no review date is not.
- Examine and describe morphology and distribution before prescribing — diffuse and uniform suggests hypo-oestrogenism, patterned and white does not
- Look at the perianal skin; a figure-of-eight distribution is not genitourinary syndrome of menopause
- Note architectural change specifically: labial resorption, clitoral hood fusion, introital narrowing
- Biopsy anything fixed, ulcerated, or unresponsive after an adequate trial rather than repeating the trial
- Set a review date when you start vaginal oestrogen, and refer for diagnostic uncertainty, multisite or refractory disease, or scarring
Why it matters
A dermatosis managed as oestrogen deficiency keeps scarring while the patient is being reassured.
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