Diagnosis of vulvar lichen sclerosus
The diagnosis of VLS can be made in the clinic, without complex tests, when the specialist has experience in vulvar pathology. The problem is not the diagnostic difficulty—it is the delay.
A fundamentally clinical diagnosis
The diagnosis of vulvar lichen sclerosus is primarily based on clinical history and physical examination. A specialist with experience in vulvar pathology can diagnose VLS during the first consultation when the presentation is characteristic: the symptom profile, the appearance of the vulvar skin, and the distribution pattern of the lesions are sufficient in most cases.
This has an important implication: VLS is not a difficult disease to diagnose when it is looked for. The real problem is different: it is often not looked for because symptoms are attributed to other causes—recurrent infections, vaginal atrophy due to menopause, contact dermatitis—without performing a targeted examination.
How the diagnosis is performed in the clinic
Clinical history
The specialist will collect information regarding the type and duration of symptoms, previous treatments and their response, history of autoimmune diseases—personal and family—and the impact of symptoms on quality of life and sexual function. This information guides the diagnosis and helps assess the severity and progression of the disease.
Clinical examination
Direct examination of the vulvar area is the central step of the diagnosis. The specialist will look for characteristic signs of VLS: white patches, thinning of the epithelium, active fissures, accumulated anatomical changes, and the distribution pattern of the lesions. This examination requires good lighting and a specialist experienced in the visual spectrum of VLS—which can be subtle in early stages and very evident in advanced stages.
Vulvar biopsy
A vulvar biopsy consists of obtaining a small tissue sample from the affected area for histological analysis. It is not essential in all cases, but it is indicated in the following situations:
> Atypical presentation—when the clinical picture is not characteristic or coexists with findings that create diagnostic doubts
> Insufficient response to treatment—if a patient diagnosed with VLS does not improve with the correct treatment, a biopsy may reveal an alternative or additional diagnosis
> Suspicion of malignancy—in the presence of lesions with characteristics that may suggest dysplasia or carcinoma: erythematous, ulcerated, indurated, or pigmented lesions that do not fit the usual VLS pattern
> Follow-up in high-risk patients—in patients with long-standing VLS or with new clinical changes
Why many women take years to be diagnosed
The average diagnostic delay for VLS is several years from the onset of symptoms. In my practice, it is common to see patients with 5, 8, or more years of symptoms before reaching a correct diagnosis. The causes are multiple:
> Misattribution of symptoms. Vulvar itching and burning are frequently attributed to yeast infections, vaginal dryness due to menopause, or contact dermatitis. These causes are treated for months or years without resolving the problem.
> Lack of targeted examination. A standard gynecological consultation does not always include a detailed examination of the vulvar area with specific attention to the signs of VLS. If it is not looked for, it is not found.
> Normalization of symptoms. Many patients—and some professionals—assume that certain vulvar symptoms are “normal” with age or menopause. They are not.
> Reluctance to consult. The intimate nature of the symptoms means that many women take a long time to seek help.
Every year of diagnostic delay is a year of disease progression without proper treatment.
When to request a second opinion or a specialized assessment
Consult with a specialist in vulvar pathology if:
> You have persistent vulvar itching that does not respond to standard treatments
> You have been diagnosed with recurrent candidiasis but antifungals do not work well
> You have white spots or changes in the appearance of the vulvar skin
> You have a diagnosis of VLS but have doubts about the treatment you are following or its results
> You have been told that your symptoms are “normal for your age” but they continue to affect your quality of life