What vulvar changes are most suggestive of lichen sclerosus rather than simple dryness?

Lichen sclerosus can look a lot like simple menopausal dryness, but there are a few changes that really point more strongly toward lichen sclerosus rather than just low estrogen.

Here at Alloy, we describe lichen sclerosus as causing thin white patches and fissures on the vulvar skin, along with cracking and bleeding, especially around the vulva and the perianal area. The itching is often intense and can be worse at night. These aren’t typical features of simple dryness.

From the medical experts featured in our videos, a few other red flags come up often. You might see pale, papery looking skin, sometimes with loss of the labia minora, and in some cases the clitoral hood can tighten or hide the clitoris under thicker skin. Those structural changes are not part of genitourinary syndrome of menopause, which is the dryness and thinning caused by low estrogen. Dr. Corinne Menn explains this really clearly in the chapter on recognizing persistent vulvar itching in this video: Lichen sclerosus vs GSM.

If dryness from menopause is the issue, symptoms usually improve with local estrogen therapy for the vulva and vagina. When itching persists even with correct use of vaginal estrogen, it’s a sign to get a careful vulvar exam to rule out lichen sclerosus. Diagnosis usually requires a biopsy, and treatment is different. Lichen sclerosus needs a high potency prescription steroid to control inflammation, sometimes along with local estrogen for overall tissue health.

If you want to learn more about dryness and itching from menopause, you can take a look at our article on vaginal itching here: Vaginal Itching and Menopause.

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