Severe postmenopausal vulvar synechia

Specialty: Gynecology and breast.

• Acquired vulvar coarctation
• fusion of the labia minora
• vulvar stenosis due to atrophy

Why it occurs

• Adhesion and fusion of the medial surfaces of the vulvar labia minora and the clitoral hood secondary to a state of extreme and prolonged hypoestrogenism, frequently associated with untreated vulvar lichen sclerosus or severe chronic inflammatory processes of the vulvar mucosa

Initial workup

Detailed vulvovaginal physical examination (a translucent or fibrous midline of cutaneous fusion is observed that joins both labia minora, totally or partially covering the vaginal introitus and the urethral meatus). Vulvoscopy with punch biopsy under local anesthesia of the skin edges if the presence of lichen sclerosus or an underlying vulvar intraepithelial neoplasia is actively suspected.

Standard management

• Estriol vulvar cream 0.1% applied directly to the fusion line of the labia minora by gentle but firm massage twice a day for a minimum of 4 to 6 weeks — of choice in cases of fine or partial synechiae, with high rates of conservative resolution
• Clobetasol propionate cream 0.05% if the synechiae is associated with active lichen sclerosus. If the synechiae are dense, thick and fibrous, or do not respond to topical hormonal treatment, manual surgical separation under local anesthesia or sedation (perineal synechiotomy) is required, followed by immediate application of local estrogens and soft dilators to prevent recurrent adhesive scarring (note: meticulous local hygiene is essential during the healing phase).