Ease Into Prep with a PANCE^® Question of the Day

The correct answer is D. In any woman who has persistent vulvar pruritis that is unresponsive to treatment, biopsy should be considered. In a postmenopausal patient this is even more essential, as squamous cell carcinoma of the vulva is more common in this age group. Other risk factors for the development of squamous cell carcinoma include multiple sexual partners, history of abnormal Pap smear, smoking, immunosuppression, and poor hygiene. Patients who have persistent genital pruritus are often treated for candidiasis or are treated with steroids, with no real diagnosis being made. This patient has no evidence for infection on her speculum examination or wet prep. The proper management of a postmenopausal patient who has persistent pruritis unresponsive to treatment is a biopsy.

To prescribe clotrimazole cream (choice A) would be appropriate if the patient had candidiasis. This patient, however, who has no significant vaginal discharge and no pseudohyphae, does not have evidence of candidiasis (i.e., a yeast infection).

To prescribe metronidazole gel (choice B) would be appropriate if the patient had bacterial vaginosis. This patient has no significant vaginal discharge and no clue cells on the normal saline wet prep. She therefore does not have bacterial vaginosis, and metronidazole gel would not be the most appropriate next step in management.

To schedule the patient for re-examination in 1 year (choice C) would not be correct. This patient has suffered with pruritis for 2 years and therefore needs to have her problem addressed as soon as possible. Perhaps more important, to delay a biopsy for a year could result in progression of a possible malignancy.

To perform a vulvectomy (choice E) on this patient would not be indicated at this point. This patient currently has longstanding pruritis of unknown etiology. She therefore requires a biopsy. If the biopsy reveals squamous cell cancer of the vulva, a vulvectomy would be appropriate management.

PEARL: Postmenopausal patients who have persistent vulvar lesions must undergo biopsy, which will yield a definitive diagnosis that ranges from lichen sclerosis to squamous cell carcinoma.