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BackTable / OBGYN / Article
Common & Complex Vulvovaginal Diseases: From Diagnosis to Management
Audrey Qian • Updated Aug 25, 2025 • 34 hits
Vulvovaginal diseases encompass a range of conditions that affect the vulva and vagina, such as infections, inflammation, and skin conditions that cause burning, pain, and itching. Common vulvovaginal diseases that result from infections include Candidiasis and STDs, while skin conditions include lichen sclerosus and vulvodynia. Despite its common occurrence, vulvovaginal disorders may be complex to manage. Many OBGYNs struggle with diagnosis and treatment, especially when topical treatments do not improve symptoms.
OBGYN Dr. Hope Haefner covers a streamlined clinical workflow that enables accurate diagnosis and approaches to symptom management for both common and complex vulvovaginal conditions. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Comprehensive, structured intake surveys and symptom-based triage are critical for efficiently directing patients with vulvar symptoms to the appropriate provider and guiding initial differential diagnoses.
• Diagnostic precision depends on early identification of symptom patterns, such as self-perpetuating itch-scratch cycles or dyspareunia in menopause, and targeted testing tools including the cotton swab test and yeast cultures. These approaches not only help to differentiate types of vulvodynia but also guide non-surgical treatment strategies.
• Broader differentials should be considered for atypical presentations, including molluscum contagiosum, pemphigus vulgaris, and Crohn’s disease. Updated anal neoplasia guidelines support incorporating anal cytology into care for patients with high-grade vulvar lesions.
• Commonly diagnosed vulvodynia and the more uncommon condition hidradenitis suppurativa could still be treated more aggressively and intervened earlier via ISSVD or ASCCP guidelines. Timely management of early-stage hidradenitis suppurativa may prevent progression to a severe stage that requires surgical treatment.
Table of Contents
(1) Intake to Differential Diagnosis: Optimizing Clinical Workflow in Vulvovaginal Diseases
(2) Symptom-Guided Assessment in Vulvodynia: Clinical Patterns &Targeted Testing
(3) Beyond the Vulva: Integrating Anal Pre-Cancer Screening & HPV Vaccination
(4) Bridging Gaps in Vulvar Disease Care: Early Intervention in Vulvodynia & Hidradenitis Suppurativa
Intake to Differential Diagnosis: Optimizing Clinical Workflow in Vulvovaginal Diseases
Before patients with vulvar symptoms undergo a physical exam, comprehensive intake surveys are used pre-visit to help stratify them based on symptoms and anticipated treatment needs. These surveys not only direct patients to more specific providers, but they also guide the initial differential diagnosis. Some common presentations include vulvodynia, pruritus, and lichen sclerosus.
During clinical examination, a cotton swab test plays a key role as an early diagnostic step for patients presenting with vulvar pain, done before other tests to avoid heightening pain sensitivity as anticipated from prior contact. Burning or itching prompts yeast cultures, and in select cases of unclear diagnoses or surgical planning, clinicians review pathology slides. This tiered approach streamlines workup, reduces unnecessary interventions, and ensures patients are evaluated by the most appropriate provider from day one.
[Dr. Jessica Ritch]
Let's start with the common symptoms or complaints that you hear people come in with. Can you talk about some of the things that you typically come across?
[Dr. Hope Haefner]
I'd like to first clarify symptoms versus signs, because often people do mix that up. Symptom is something the patient feels, whereas a sign is something you as a healthcare provider or the patient can see. Some of the symptoms. When we first opened our center for vulvar diseases, I would say 70% to 80% of our patients had vulvodynia. That's a symptom. Pain, burning, normal-appearing vulva. I realized quickly that I needed to learn pain management.
As the years progressed, it actually changed in that family medicine got interested in researching and treating this patient population. They started seeing the majority of vulvodynia patients that didn't need surgery. Now what's taken over is a symptom of itching, pruritus. We would see in one clinic, if I were seeing patients alone, we would probably see 70% of the patients have lichen sclerosus. You do need to know that some of these patients with these other conditions have pain too. You need to know how to treat pain to take care of those conditions. I would say lichen sclerosus is our most common diagnosis at this point. We also see a lot of high-grade pre-cancers. We see some hidradenitis suppurativa, Paget's disease, all different conditions.
[Dr. Jessica Ritch]
How do you start to group people into these different categories of what you're looking for based on the symptoms and what signs are you looking for? How do you start to put that together and categorize the issues that people are dealing with?
[Dr. Hope Haefner]
Before a patient actually gets an appointment in our clinic, they fill out an intake survey that is very long but very helpful for us to put them into a differential diagnosis. For example, some of the providers in our clinics don't operate. Some are family medicine, et cetera. Those that are family medicine are going to see the patients that don't need surgery, whereas someone comes in with an active Bartholin cyst that we think we might need to marsupialize, they'll see one of the gynecologists that operates. We have an intake survey.
After we see the intake survey's filled out, they get an appointment appropriate for what they have with who they need to see. Then some of the patients fill these intake surveys out on paper, whereas others do it electronically. No matter what, whichever way it is, I know what I need to ask them when I go into the room. I quickly go over the intake survey. Often, I know even before I examine the vulva, what is in my differential. Then we start the physical exam. If needed, we go with further testing.
I always do a cotton swab test on someone that complains of vulvar pain before I do anything else on them, because once you touch the vulva, you've sensitized them to any other touch. I often will do yeast cultures on patients that have itching or burning because certain species of yeast can cause burning. We like to obtain any outside records of path diagnoses. When we first started our center for vulvar diseases, we would ask for the slides to be sent to us for our pathologist to review. In the cost effective environment today, we don't do that unless it's somebody that really has a questionable diagnosis or needs surgery, et cetera.
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Symptom-Guided Assessment in Vulvodynia: Clinical Patterns &Targeted Testing
In addition to comprehensive intake processes, nuanced interpretation of symptom patterns play a pivotal role in helping to accurately diagnose vulvar conditions. In particular, self-perpetuating itch-scratch cycle may often point to lichen simplex chronicus, while dyspareunia in menopausal patients may signal genitourinary syndrome of menopause – a condition that benefits from but is often under-treated with vaginal estrogen. Additionally, the cotton swab (Q-tip) test remains a crucial protocol for assessing pain intensity and localization to help distinguish between generalized and localized vulvodynia.
To stratify patients with different types of vulvodynia, all new patients should also be tested for yeast infection before treatment is tailored accordingly. Localized vulvodynia, commonly vestibulodynia, may respond to topical therapies, pelvic floor physical therapy, or targeted injections such as Botox. If pain does not improve, vestibuloectomy may be performed, though its use has declined with broader success in non-surgical management.
[Dr. Jessica Ritch]
Then you said you have this pretty comprehensive intake form. Just looking at the intake form, you're able to recognize certain patterns and put your differential together. Can you, and I know that this is a big question, but can you tell us some of the most common things that you see like for the lichen or for other areas? What are those couple of things that you're highlighting on the intake form that are making you lean in one way or the other before you examine somebody?
[Dr. Hope Haefner]
If they're itching, if they're scratching, if they've had a biopsy that shows lichen simplex chronicus, we're going to think, oh, they've got the itch, scratch, itch cycle, which is meaning they itch, so they start to scratch and it feels so good, but after they've scratched, they itch even more and they start going down the tube. If they have a recent atrophy diagnosis, for example, they're in menopause and they have pain with intercourse and they haven't tried any estrogens, just from looking at their intake survey, pain with sex, recent menopausal, we're going to think about doing something that is estrogen forming to help them, like a Vagifem suppository or other estrogen suppositories, topical estrogen. Sometimes we'll use systemic estrogen dependent on the age and other conditions with the patient.
[Dr. Jessica Ritch]
I think that's one of the things that I'm most often surprised about with people with the vulvar and vaginal complaints, how many times they've tried a million different topical things, but haven't actually tried estrogen. It's always really important to make sure pretty much everybody's getting some vaginal estrogen at some point. Not everybody, of course, but those people with the genitourinary syndrome of menopause, of course. Then you're coming in, you're starting to examine them. You said that you start with a cotton swab test. Tell me a little bit more about what you mean by that cotton swab test.
[Dr. Hope Haefner]
We keep track of the various points on the vulva that have any potential for pain. Generally, I'll start at the lateral labia majora. If they have pain there, I'll go down to the thigh and down to the knee even. Sometimes they have pain down there. If I'm in the big toe, that's out of my area. That doesn't even make sense from the pudendal nerve distribution and ilioinguinal genitofemoral nerve distributions.
Usually, we start in the labia majora, superior and inferior. Then we go to the interlabial sulci, then the labia minora. I tell them as I go, now I'm going to touch here so they're not startled. Then once I've done the labia minora, I spread them gently and I do the interlabia minora including the vestibule. I happen to be right-handed. I start the vestibule at the ten o'clock position in lithotomy. Then I do two o'clock, four o'clock, six o'clock, eight o'clock.
After that, we will touch the clitoris gently with a cotton swab and then the perianal area. We try to keep track of mild, moderate, severe, where it's located, and what the intensity is. That helps us know if they're getting better. Often, the patient will know when they see us at the next visit. Either hopefully they say, I'm better. You can't help everyone all the time, particularly on the first return visit. Some say, I'm worse. That helps us know from the Q-tip test.
[Dr. Jessica Ritch]
When we're talking about the Q-tip test, you're looking for sensitivities, you're looking for allodynia, you're just doing that light touch in all of those areas to see where they're having the specific issues, if it's more generalized or more specific.
[Dr. Hope Haefner]
Right. There's two types of vulvodynia, generalized and localized. Generalized is where the majority of the vulva is involved with pain, whereas localized, there's two subcategories of localized. Either clitoridynia, which is not nearly as common as the other subcategory, and that's called vestibulodynia, where the vestibule from the hymen on out to Hart's line is where the pain is located, and that's localized.
[Dr. Jessica Ritch]
When you're looking at vulvodynia, of course, there are all sorts of different categories that can be causing that vulvodynia, as vulvodynia is a symptom, not necessarily a diagnosis. How do you start to group people into what might be more infectious, what might be more inflammatory, what might be more neurologic? How do you move forward in that area?
[Dr. Hope Haefner]
The majority of the new patients get a yeast culture. We identify the species and then, depending on what the species is, if it's positive, we treat appropriately. There's actually an iPhone app out there that the ISSVD put out that tells you, based on the species type, what agents it's likely to respond to. We rarely ever do sensitivities to yeast. On rare occasion, if they're not better on what we already think it's going to be sensitive to.
If their pain goes away with an antifungal, that's great. They didn't have vulvodynia to begin with. They had vulvar pain secondary to the yeast infection. If their pain doesn't get better, we start them on all different things. If the vulva looks normal, we're going to start them on some topical compounded medicines, or if they haven't tried 5% lidocaine ointment, we'll try that. If it's generalized, you still can use some of the topicals. If it's severe and generalized, I'll often go to the oral medications. Oral tricyclic antidepressants, the oral anticonvulsants.
Then you mentioned, I believe, physical therapy. I find physical therapy extremely helpful for localized vulvodynia as well as some generalized vulvodynia. If it's localized and they haven't gotten better, we do some Botox injections in our clinic. We tend to do them with mild sedation. If that fails, we will do vestibulectomies with vaginal advancement. Often, the other measures now work. When we first opened our center for vulvar diseases, I would say the majority of time, we would be doing maybe 100 vestibulectomies in a year. Now, it's at most 5 or 10 vestibulectomies in a year because other things are working.
Beyond the Vulva: Integrating Anal Pre-Cancer Screening & HPV Vaccination
When vulvovaginal presentations fall outside the scope of common conditions such as lichen sclerosus or vulvodynia, clinicians may expand their differential to include less common diagnoses, including molluscum contagiosum, pemphigus vulgaris, or Crohn’s disease. Updated guidelines from the International Anal Neoplasia Society (IANS) also focus on anal cytology and anoscopy in select at-risk patients, particularly those with high-grade vulvar lesions.
The use of HPV vaccination, even in patients over 45, has also shown promise as a therapeutic for patients with high-grade disease. Ongoing comparative studies are still underway to clarify best practices and support a more integrated approach to the management of vulvar conditions.
[Dr. Jessica Ritch]
[W]hen you start to see things like you just described, it makes us start looking for these less common things like molluscum, not that that's uncommon in general, but looking for molluscum or pemphigus vulgarum, or all of these less likely things, or looking at Crohn's. When we're looking at the less common things out there, do you have an approach to how you start to rein things in when it's not such a common symptom like a lichen sclerosus or a typical vulvodynia?
[Dr. Hope Haefner]
Before we get to that, I think when we're talking about pre-cancers, something new that's out there, and actually it's been done for many years, but there is a new anal pre-cancer cancer guideline that came out from the International Anal Neoplasia Society, IANS it's called. This came out just this year. As many of us are gynecologists and we're doing vulvoscopies for high grade of the vulva, I think we have to think about the anus and do anal cytology.
If you have someone that's willing to do an anoscopy then, and go ahead and treat if you find high grade of the anus. Also the HPV vaccine with use of the pre-cancers, we're finding some good results with using that in this population. Obviously the high grade is decreasing as well as the use in patients that have high grade already. We're actually giving HPV vaccine to some of the patients that are over 45 to try to help with getting a cure.
[Dr. Jessica Ritch]
Are you doing the anoscopy and sampling yourself, the cytology? Are you sending them to a GI, or how are you arranging that?
[Dr. Hope Haefner]
I think us as gynecologists that do colposcopy and have been trained in colposcopy are very capable of doing anoscopes. Once you learn the procedure. The IANS does have a course where they teach anoscopy. It's a very good course. They have a basic one and an advanced one. We do it. All of the providers in our clinic have been trained on it. If they see something on cytology, we actually use the ASCCP guidelines up to this point because our population is an HIV positive, like some of the earlier literature from IANS.
Although we're going to compare our rates of high grade, low grade in patients with H-cell of the vulva, high grade, low grade of the anus, and compare it to some of the studies that IANS has done. We actually have a study we're doing right now on that and see whether we can really-- we're not screening quite as frequently as the new recommendations from IANS says to do. We're going to look because I think we have a lower risk population with our women that have HPV of the vulva that is high grade. We don't have a lot of IV drug abusers. We obviously don't have the men who have sex with men population. We're looking at that. Hopefully that study will be out in the next year.
Bridging Gaps in Vulvar Disease Care: Early Intervention in Vulvodynia & Hidradenitis Suppurativa
Besides recommending anoscopy for patients with vulvar conditions, Dr. Haefner addresses the undertreatment of vulvodynia. Delays in addressing vulvodynia makes treatment harder to implement, underlining the importance of knowing ISSVD and ASCCP early intervention guidelines. A more unusual condition, hidradenitis suppurativa (HS) also requires more aggressive early management than it often receives.
HS, particularly in vulvar, groin, and buttock regions, can escalate quickly from stage 1 – early furuncles that usually respond well to topical agents and hormonal therapy – to stage 3 disease. By this point the patient would require extensive surgery and skin grafting. Early identification of patients with multiple boils, especially when they appear in axillae, inframammary areas, or under the breast, may prompt timely initiation of stage-appropriate therapies. Such therapies may include oral contraceptives with low androgenic activity, clindamycin lotion, and hygiene regimens. Clinical vigilance during early presentations can significantly reduce patient morbidity and the need for invasive procedures.
[Dr. Jessica Ritch]
I love everything that you've shared with us so far. I think it's been really eye opening. I wanted to ask just, what is it that you think that the rest of us are missing in our care of vulvar conditions? I know there's probably a lot of things on the list. What are the top things that you think the rest of us OBGYNs are missing and we could do to improve, other than doing, of course, the anoscopy that you just recommended?
[Dr. Hope Haefner]
I think that sometimes the patients with vulvodynia are not treated aggressively enough. The longer you have the vulvodynia, the worse it can get, the harder it can get to cure. I recommend that those of you that aren't familiar with the vulvodynia guideline from the ISSVD, ASCCP, et cetera, we've done a lot of work through those organizations, and do the reading of the guideline and start treating those patients early on that need help with vulvodynia.
Other conditions, one of my most unusual conditions that I think could benefit for more aggressive treatment is hidradenitis suppurativa. Hidradenitis suppurativa is a devastating condition. It's one thing to have it in the axilla. It can be horrible, I totally understand that. When you've got it in your groins, the vulva, and a lot of our patients have it in the buttock area too, it takes over their life. I couldn't imagine how miserable they must be. If we could start seeing patients with furuncles or early boils of hidradenitis and start treating that appropriately, I think we could probably keep a lot of patients from going on to stage 2.
There's three stages of hidradenitis suppurativa. If you see someone in stage 1 and get them on the stage 1 medications, 75% are going to stay at that or get even better that you're not going to need medicines long-term. Once they get to stage 2, the medications get more difficult, the treatments get more difficult. Then once they get to stage 3, and that's where a large portion of the vulva is involved, the buttocks involved, it's a surgical condition. What we do for that are vulvectomies, part of the abdomen removal if a disease is up towards the umbilicus, and buttock removal, and wound vacs, and grafts, sometimes flaps, I prefer the grafts.
If we could just get those stage 1s on the right medicines, OCPs, if they are contraindicated ones that don't have high androgen profiles in them, if we could get them on clindamycin lotion, the appropriate cleansing bars, topical steroids if they need it. Really steroids, though, aren't the answer for hidradenitis. Occasionally, we will use intralesional steroid injections. That's what we need to do. Keep them in stage 1. On that handout I mentioned to you, we have lots and lots of recipes for how to treat stage 1, how to treat stage 2, how to treat stage 3.
They're using a lot of Humira, adalimumab in dermatology for stage 2, stage 3. I think it's great for stage 2. For stage 3, in my opinion, surgery, the vulvectomy with skin grafts, wound vac. Eventually after a couple of wound vac changes, we go to skin grafting with a Reston. They're in the hospital about 17, 18 days on the average. These women are happy. They're no longer having that drainage. You do have to rule out Crohn's disease though, because if you operate on a Crohn's patient, it's likely to come back.
[Dr. Jessica Ritch]
For those people that you're trying to catch in stage 1, how do you note the differences between somebody with a very early hidradenitis suppurativa versus somebody who's maybe got a few boils from chronic folliculitis or just other boils in the area? How do you put somebody into that category and get them on more aggressive treatment?
[Dr. Hope Haefner]
If they have one small furuncle, that's not going to be hidradenitis. If they have multiple boils, you're at hidradenitis. Look in their armpits. Not everybody with vulvar hidradenitis has axillary hidradenitis, but a lot of them do. Look in the armpits. Look under the breast. Some women get it under their breast. There's actually a lot of hidradenitis groups. If you happen to have a patient with hidradenitis, they have a patient-developed hidradenitis suppurativa group that has wonderful information on it.
We get them to stop smoking if they smoke. We also do that with the high-grade patients. The longer they smoke, the harder it is for us to get rid of the disease. We start the hidradenitis patients on a lot of over-the-counter things, vitamins and things. Again, that's all in our recipe in there. We have to get that under control and make their life better because they are miserable.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2024, September 3). Ep. 64 – Vulvovaginal Disorders: Diagnosis & Treatment Approaches [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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