Vulvar diseases: Conditions in adults and children.

The most problematic vulvovaginal conditions are familiar to dermatologists but may exhibit distinct clinical features or medication management because of the anatomic location. The second article in this continuing medical education series focuses on management pearls for treating vulvar diseases. We highlight key conditions, such as lichen sclerosus, erosive lichen planus, and vulvodynia. In addition, we review conditions that dermatologists may be less familiar with, such as plasma cell vulvitis, desquamative inflammatory vaginitis, vulvar aphthae, and low estrogen states. Nearly 1 in 6 women experience undiagnosed and untreated vulvovaginal discomfort at some point in their lives. Physicians who treat vulvar disorders will improve the quality of life of countless women.

Vulvar diseases: Approach to the patient.

Patients with vulvar dermatoses often delay seeking medical treatment because of anxiety and embarrassment. Moreover, women frequently self-treat with various home remedies and see multiple clinicians before presenting to a dermatologist. Despite serving as the primary providers for patients with vulvovaginal symptoms, gynecologists typically receive limited training in the causes and management of these conditions. Dermatologists are experts in the evaluation and management of cutaneous disease and should be the caretakers of all skin, including the genitalia. Vulvar disorders are underrecognized by dermatologists for numerous reasons: inadequate training, lack of comfort with both interview and examination techniques, and unfamiliarity with normal anatomic variations. The first article in this continuing medical education series on vulvar dermatoses reviews the fundamentals, approach, and techniques that can be used to ensure a successful visit for both patient and provider.

Inflammatory Vulvar Dermatoses.

Inflammatory vulvar dermatoses affect many women, but are likely underdiagnosed due to embarrassment and reluctance to visit a health care provider. Although itch and pain are common presenting symptoms, the physical examination can help distinguish between different disease entities. Because many women's health providers have minimal training in the categorization and management of dermatologic disease, definitive diagnosis and management can be difficult. Herein, strategies for diagnosing vulvar lichen sclerosus, lichen planus, contact dermatitis, lichen simplex chronicus, and psoriasis are discussed along with basic management of these diseases, which commonly involves decreasing inflammation through behavioral change, gentle skin care, topical corticosteroids, and systemic therapies.

Identifying competencies in vulvar disorder management for medical students and residents: a survey of US vulvar disorder experts.

OBJECTIVE: The study aimed to perform a content validation process by surveying vulvar disorder experts to identify evidence-based competencies appropriate for use in developing vulvar curricula for medical trainees. MATERIALS AND METHODS: We identified 65 potential vulvar disorder competencies from literature review and expert opinions. Survey participants rated these competencies from 1 (not at all important) to 4 (highly important) in the training of 3 different groups of learners as follows: medical students, obstetrics and gynecology residents, and dermatology residents. We administered the survey to all US-based clinical members of the International Society for the Study of Vulvovaginal Disease as of September 2008 (n = 90). The content validity index and asymmetric CI were calculated for each curricular competency for each group of learners separately and used to identify competencies for use in curricula development. RESULTS: Forty-seven surveys were returned, yielding a response rate of 52.2%. Obstetrician-gynecologists represented 66% of the study sample, followed by dermatologists (15%), and nurse practitioners (9%). Seventy-nine percent of experts received their training by self-teaching, which included mentored experiences (62%) and attending conferences or courses (62%). Only 19% received vulvar training during residency and 11% during fellowship. Four curricular competencies met content validity criteria for medical students, 60 competencies for obstetrics and gynecology residents, and 47 competencies for dermatology residents. The differences between the 2 groups of residents focused on vulvovaginal pain and infection, examination, and procedures of the vagina. CONCLUSIONS: The competencies identified in this study can aid in the development of targeted curricula for medical students, obstetrics and gynecology residents, and dermatology residents.

Pigmented lesions of the vulva.

Approximately one of every 10 women has a pigmented vulvar lesion. Given the risk of melanomas and pigmented vulvar intraepithelial neoplasia (squamous cell carcinoma in situ), proper evaluation of vulvar pigmented lesions is critical. Most vulvar lesions are benign; however, vulvar lesions grossly, dermoscopically, and histologically can appear atypical compared with pigmented lesions on the rest of the body. Thus, it is imperative to use not only a keen eye but also a low threshold for biopsy.

Positive predictive value of specific mammographic findings according to reader and patient variables.

PURPOSE: To evaluate the risk of cancer (positive predictive value [PPV]) associated with specific findings (mass, calcifications, architectural distortion, asymmetry) in mammographic examinations with abnormal results, to determine the distribution of these findings in examinations in which the patients received a diagnosis of cancer and examinations in which the patients did not, and to analyze PPV variation according to radiologist and patient factors. MATERIALS AND METHODS: HIPAA-compliant institutional review board approval was obtained. PPV of mammographic findings was evaluated in a prospective cohort of 10,262 women who underwent 10,641 screening or diagnostic mammographic examinations with abnormal results between January 1998 and December 2002 in the San Francisco Mammography Registry. The cohort was linked with the Surveillance Epidemiology and End Results program to determine cancer status among these women. PPVs were calculated for each finding and were stratified according to patient characteristics, cancer type, and radiologist reader. RESULTS: Cases of breast cancer (n = 1552) were identified (invasive, n = 1287; ductal carcinoma in situ, n = 270); in five, both kinds of breast cancer were recorded. Overall, of the number of interpretations, masses were most frequently noted in 56%, followed by calcifications in 29%, asymmetry in 12%, and architectural distortion in 4%. Masses, calcifications, architectural distortion, and developing asymmetry demonstrated similar PPVs in screening examinations (9.7%, 12.7%, 10.2%, and 7.4%, respectively), whereas one-view-only and focal asymmetry demonstrated lower PPVs (3.6% and 3.7%, respectively) and were a frequent reason for an abnormal result (42%). Overall, one (5%) in 20 invasive cancers was identified with asymmetry, one (6%) in 16 invasive cancers was identified with architectural distortion, one (21%) in five invasive cancers was identified with calcifications, and two (68%) in three invasive cancers were identified with a mass. CONCLUSION: Five percent of invasive cancers were identified with asymmetry, and asymmetry is more weakly associated with cancer in screening examinations than are mass, calcifications, and architectural distortion.