Is It Just Menopause Dryness? Understanding Vulval Lichen Sclerosus

We talk a lot about hot flashes, night sweats, and brain fog as we navigate perimenopause and menopause. But what about the changes... down there? Many of us expect some vaginal dryness. That’s Genitourinary Syndrome of Menopause (GSM), and it’s incredibly common.

But what if your symptoms feel different? What if it’s not just dryness, but an intense, persistent itch that wakes you up at night? Or what if you’ve noticed changes to the skin itself—like pale patches or a different texture?

If this sounds familiar, you are not alone, and it’s not something you just have to "live with." It might be a condition called vulval lichen sclerosus, and it’s time we talked about it openly.

What Exactly is Vulval Lichen Sclerosus?

Let's clear up a few things right away. Lichen Sclerosus (often just called LS) is not an infection, it's not contagious, and it's not caused by poor hygiene.

At its core, LS is a chronic inflammatory skin condition. Think of it as being in the same family as eczema or psoriasis, but it specifically likes to affect the skin of the vulva (the external genital area) and sometimes the skin around the anus.

It’s believed to be an autoimmune condition, meaning the body's immune system mistakenly attacks healthy skin tissue. While it can affect women at any age (even young girls), it has a known peak in diagnosis for women in their perimenopausal and postmenopausal years, right when we're dealing with so many other hormonal shifts.

The Menopause Connection: A "Double Whammy"

This is the number one question we hear: "Did menopause cause this?"

The short answer is no, but the timing is no coincidence. Menopause doesn't cause LS, but the low-estrogen state of menopause can absolutely make it worse or "unmask" a case that was mild or asymptomatic before.

Here's why it's a "double whammy":

1. Menopause (GSM): As estrogen declines, our vulvar and vaginal tissues naturally become thinner, drier, and more fragile. This is the GSM we mentioned earlier.

2. Lichen Sclerosus (LS): This separate, autoimmune condition adds inflammation to the mix. This inflammation is what causes the intense itching and skin changes.

When you put fragile, dry menopausal tissue together with active inflammation, the symptoms can feel magnified. The skin is already vulnerable, and the LS makes it itch, which leads to scratching, which leads to more inflammation and even tiny tears (fissures). It’s a painful cycle.

Lichen Sclerosus vs. "Regular" Menopause Dryness (GSM)

This is the most important part. How can you tell the difference? While only a doctor can diagnose you, the symptoms are often distinct.

Symptoms of Menopause Dryness (GSM)

GSM symptoms are primarily related to the loss of estrogen. They often include:

• A feeling of dryness or irritation, like sandpaper.

• Burning or general soreness.

• Pain with sexual activity (dyspareunia), often felt at the entrance of the vagina.

• Symptoms are often inside the vagina as well as on the vulva.

Telltale Signs of Lichen Sclerosus (LS)

LS symptoms are primarily related to inflammation and skin changes on the vulva (it doesn't affect the inside of the vagina).

• The Itch: This is the hallmark symptom. We’re not talking about a small, occasional itch. This is a profound, persistent, intense itch (the medical term is pruritus) that is often worse at night and can be disruptive to sleep.

• Skin Changes: This is the other key sign. You might notice pale, white, or shiny patches of skin on your vulva. The skin texture can change, becoming crinkled or "parchment-like."

• Pain & Tearing: The skin becomes extremely fragile and can bruise, split, or tear easily (fissures), causing stinging (especially with urine) or bleeding.

• Scarring (in advanced cases): If left untreated, the chronic inflammation can lead to scarring. This can cause the labia minora (inner lips) to shrink and fuse, or the skin over the clitoris (the clitoral hood) to thicken and cover it.

If you are experiencing an intense itch or have noticed any skin changes, it is essential to see your doctor.

Getting a Diagnosis: What to Expect

Here in the US, your first stop will likely be your gynecologist or primary care provider (PCP). If your case is complex or doesn't respond to initial treatment, they may refer you to a dermatologist or a vulvar disease specialist.

Trust your gut. LS is notorious for being misdiagnosed for years as recurrent yeast infections or "just bad menopause." If you've been using over-the-counter creams or even vaginal estrogen and the itching or skin changes aren't getting better, ask your doctor to specifically evaluate you for lichen sclerosus.

A diagnosis is often made by a simple visual exam by a trained doctor. However, the "gold standard" to confirm it is a punch biopsy.

This sounds much scarier than it is. Your doctor will numb a tiny spot of the affected skin (you'll feel a small pinch from the numbing shot) and take a very small sample, about the size of a pencil eraser. This sample is sent to a lab to be 100% sure of the diagnosis and to rule out anything else.

Managing Lichen Sclerosus: Your Treatment Toolkit

Okay, let's talk solutions. While there isn't a "cure" for LS (just like there isn't one for eczema), it is highly manageable. The goal of treatment is to stop the inflammation, relieve the itch, and—most importantly—prevent any future scarring or changes.

The Gold Standard: Topical Steroids

The frontline, FDA-approved treatment for LS is a high-potency topical steroid ointment, most commonly clobetasol propionate.

I know, "steroids on your vulva" sounds intense. But this is the treatment that works. It's not like a lotion; it's a powerful anti-inflammatory medicine. Your doctor will give you a very specific schedule, which usually involves using a small amount daily for several weeks to get the inflammation under control, then "tapering down" to a maintenance schedule (often just 1-2 times a week) to keep it in remission.

Using this treatment as prescribed is the single most important thing you can do to protect your skin and health.

Don't Forget Estrogen!

If you're in menopause, your doctor will likely treat both problems. They will prescribe the topical steroid for the LS, but they may also prescribe a localized vaginal estrogen (like a cream, tablet, or ring) to treat the underlying menopausal tissue thinning (GSM). This helps rebuild the health and resilience of the surrounding tissue, making it less fragile.

Smart Lifestyle & Comfort Care

These tips can make a huge difference in your daily comfort:

• Be Gentle: Cleanse the area with lukewarm water only or, if you must, a very mild, fragrance-free cleanser (like CeraVe or Cetaphil). Use your hand, not a washcloth. Pat dry gently—don't rub.

• Protect Your Skin: After bathing (and after your steroid medicine has soaked in), apply a thin layer of a simple emollient to protect the skin from friction and urine. Good options include plain petroleum jelly (like Vaseline), coconut oil, or Emuaid.

• Ditch Irritants: Stop all bubble baths, scented soaps, scented laundry detergents, fabric softeners, and scented pads or liners.

• Breathe Easy: Wear loose-fitting, 100% cotton underwear (or at least a cotton crotch). Avoid thongs. Consider sleeping "commando" at night to let the area breathe.

• Be Smart About Sex: If sex is painful, don't just grit your teeth. Use a high-quality, silicone-based lubricant (they last longer and are slicker than water-based). If pain persists, talk to your doctor or a pelvic floor physical therapist.

A Quick, Calm Note on Cancer Risk

I'm including this not to scare you, but to empower you. You may read online that LS is linked to skin cancer, and it's important to have the facts.

Untreated or unmonitored LS has a small (about 4-5%) increased risk of developing into a type of skin cancer called squamous cell carcinoma.

This is exactly why getting a diagnosis and using your treatment is so critical. Following your treatment plan and going for your regular check-ups (usually once or twice a year) dramatically reduces this risk and allows your doctor to catch any potential changes at the earliest, most treatable stage. This is a manageable condition, and you are in the driver's seat.

You Don't Have to "Just Live With It"

Vulval lichen sclerosus, especially when it piles on top of all the other changes of menopause, can feel isolating and overwhelming. But here is the good news: it has a name, it is not just in your head, and it is manageable.

By getting the right diagnosis, you can get the right treatment. You can stop the itch, prevent long-term changes, and feel comfortable and in control of your body again. This is just one more part of learning to be our own best health advocates in this new chapter.