Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

September is Menopause Awareness Month. Over the next few weeks, Dr. Patricia Allen will consult on several questions about menopausal symptoms and relief.

Dear Dr. Pat,

I am 53 years old and had my last period two years ago. In the year before menopause began, I began to have episodes of vague burning of the labia. I saw my primary care physician assistant many times for these symptoms. Each time she examined me, she diagnosed a “yeast infection” and gave me a pill for the infection.  Mostly, it didn’t seem to help but over time, the mild burning would pass.  As I progressed through menopause, the burning increased in severity. I found it more painful to have intercourse, even with lubrication, and believe me, I tried them all.

After a year of these visits and no periods, the physician assistant prescribed vaginal estrogens.  First was Premarin cream, which made the burning worse. Next, she prescribed an estrogen tablet to insert into the vagina twice a week. In spite of this treatment for menopausal change in my vulvovaginal tissues, intercourse became more painful and the episodes of burning became more frequent. I developed blisters on both labia and was tested for herpes with a culture several times.

The herpes cultures were negative, and yet I was given medication three times for this “herpes infection.” Then, I developed very painful ulcers in my mouth, prompting a visit to my competent dentist who teaches at a dental school. He quickly made the diagnosis of a condition known as lichen planus. I was treated and the symptoms were under control in a few weeks. However, I still had burning and episodic blisters on the vulvar tissue and I had become very depressed about the inability to have a sexual relationship. The treatment for menopausal change was of no help. Finally, I did research and found a specialist in vulvar disease at the university medical center. She asked careful questions, listened to me, and was very interested in my recent diagnosis of lichen planus of the mouth. She examined me and told me that I had lichen planus of both the oral and vulvar mucosa and prescribed a cream to stop the burning.  After the lichen planus episode was controlled, she prescribed treatment for the genital atrophy, which was the result of menopause but never the cause of my terrible burning. I am now without pain and am able to have comfortable intercourse.

I am writing to you because I feel that my symptoms were never taken seriously by my primary care health care provider. Because I was in “menopause,” I think my symptoms were essentially attributed to hormonal change and not evaluated properly. I was treated for a yeast infection without a culture. I was treated for herpes even though several cultures were negative. The vaginal estrogen never helped since the underlying condition was never diagnosed or treated.  How common is lichen planus and why didn’t my original health care provider know that my symptoms were not just the result of menopause?

Judy

Dear Judy,

I am sorry that you had three years of suffering and felt that you were not heard.  As your experience points out, it is very important that a health care provider listen to the patient, ask the right questions, perform a careful exam and order correct tests. Finally, if the findings and test results don’t make sense, the health care provider should, ask “What am I missing?” They should then refer the patient to someone for a second opinion.

Dr. Monica Peacocke, an immunologist who is a specialist in vulvovaginal disorders, will discuss the differences in diagnostic presentations of vulvovaginal disorders with a focus on lichen planus and menopause.

Thank you for sharing your story.

Dr. Pat