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23. Vulvar Cancer Screening with Dr. Melissa Mauskar
107 Plays7 months ago
Vulvar cancer screening refers to checking for signs of vulvar cancer in individuals who may not have symptoms. Vulvar cancer is rare, and there isn't a standard screening test specifically for it like there is for cervical cancer with Pap smears. However, early detection often relies on regular pelvic exams and self-examinations to look for any abnormalities or changes in the vulvar area. Dr. Melissa Mauskar joins me to discuss vulvar screening in this episode.
Dr. Melissa Mauskar is a Dermatologist and Associate Professor in the Departments of Dermatology and Obstetrics and Gynecology at UT Southwestern in Dallas, Texas. She is the Director of Genital Dermatology and Women's Health and is an International expert in Lichen Sclerosus and Vulvar dermatoses. Melissa is a fellow of the International Society of the Study of Vulvovaginal Diseases (ISSVD) and the Secretary General of the North American Chapter of the ISSVD. In addition to caring for patients with lichen sclerosus, she is active in clinical research and passionate about patient quality of life and health literacy initiatives. Melissa is the Founding President of the Vulvar Dermatoses Research Consortium (VDRC), an expansive group of healthcare practitioners and trainees in North America dedicated to advancing the field of vulvar health.
Featured in this episode:
- When to see your GYN or healthcare practitioner
- Look at your vulvar once a month
- Lichen Scelorus symptoms
- Check out the vulvar poem here
- Get Dr. Melissa Mauskar’s free e-book on Lichen Scelorus here
- Listen to the Vulva poem by Dr. Pope here
Follow us on social media:
- Instagram: @drrpope
- TikTok: @vulvadoctor
- Twitter: @drrpope
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Transcript
Patient's Initial Fear of Vulvar Cancer
00:00:00
Speaker
So I had this patient who came to see me because she was worried that she had something on her vulva that was cancer. She said that she actually had noticed it a while back, maybe even a year or more. And she was so terrified by it that she actually was a little bit of a denial and she didn't want to see anyone to see that it was cancer or to confirm that it was cancer, I guess. So she put it off, put it off, had a lot of other things going on in her life. And then she finally decided to face the possibility that this was a cancer growing on her vulva that would require extensive treatment, chemotherapy, radiation surgery. She wasn't sure, but she was terrified. So she told me this story and saw me in the office and was telling me about what she saw, how she felt.
Diagnosis and Relief: Benign Cyst Found
00:00:50
Speaker
And then I had her get undressed with an examination gown so I could examine her And you know what? It was an absolutely benign cyst. Something that even without a biopsy I could say was benign. It was something we call an inclusion cyst. And I looked at it and I said, this is absolutely not cancer. We can do a biopsy to confirm if that would make you feel better, but this is an inclusion cyst. And she started crying. The amount of relief that she experienced from just the examination, just
00:01:26
Speaker
two minutes of someone who is experienced enough, has seen enough of these. It's kind of an expert, I guess you could say, to tell her that this was not cancer. It was all she needed. And she could let go of more of a year of worrying, of anxiety, of concern.
00:01:43
Speaker
that she was walking around with a death sentence. I couldn't believe that she had held on to it that
Understanding Vulvar Health Concerns
00:01:49
Speaker
long. And it made me realize that there are so many women out there who actually are not even familiar with what is going on with their vulvas. They don't look because it's hard to see. They don't really even notice if they have a dupum cyst or anything. And they don't know when to be concerned and when not to.
Insights from Dr. Melissa Moscar
00:02:08
Speaker
So welcome back everyone to Our Womanity. Today to talk more about vulvar skin conditions, I have with us Dr. Melissa Moscar. She's a dermatologist and associate professor in the departments of dermatology and obstetrics and gynecology at UT Southwestern in Dallas, Texas. She's the director of genital dermatology and women's health and is an international expert in lichen sclerosis and vulvar dermatoses. Dr. Marskar is a fellow of the ISSVD, that's the International Society of the Study of Vulvovaginal Diseases. In case you didn't know, there is a society that's dedicated to vulvar conditions and the Secretary General of the North American Chapter of the ISSVD. In addition to caring for patients with lichen sclerosis, she's an active clinical researcher and passionate about patient quality of life and health literacy initiatives.
00:02:55
Speaker
She's the founding president of the Volvar Dermatosis Research Consortium, an expansive group of healthcare practitioners and trainees in North America dedicated to advancing the field of Volvar health. And as an advocate of women's health initiatives, she aims to improve the quality of life of women and their interpersonal relationships and empower patients to speak more freely about their conditions. How amazing is Dr. Moskar? Don't you all want to see her as your dermatologist?
00:03:20
Speaker
I still get the goosebumps. I mean, especially being interviewed by someone as amazing as yourself. So I feel like I've loved like just getting to know you through all of these initiatives and really moving the bar forward in so many different things. So thank you so much for having me. Oh my gosh, thank you. Well, I feel like we are contemporaries. We are both passionate about women's health and about sexual health and of all of our conditions. And I love your um your picture in the background of the wall of Viva La Volva.
When to Worry About Vulvar Conditions
00:03:49
Speaker
this is
00:03:52
Speaker
I'm so glad to have your time today. And I wanted to dive right in and ask you, you know, when should women really have a concern about vulvar skin conditions? Or when should they be worried about their vulvas externally?
00:04:07
Speaker
in general, because I don't think we really get told, you know, go see, go see a dermatologist for this or go see a vulvar specialist when you have these issues, we just say go see your primary care provider, you know, so no and I think our healthcare care industry has done a really good job of screening for different cancers or conditions.
00:04:25
Speaker
You know, I think that we're all taught about self-rest exams, but no one really even says the word vulva out loud. Like we're taught very early on, it's very taboo. We call it a private part pancake, hoo-ha, you name it. you yeah ah is any Insert your term that is not a proper anatomy there. But I think initially we're we're taught just to kind of ignore or pretend that there's nothing there. So when you have itching or pain,
00:04:54
Speaker
definitely bring it up with any doctor, whether it's your dermatologist, gynecologist, general practitioner. So when you have symptoms, definitely a reason to bring it up. But I'll also say people often look at their bullets for the very first time when they do have symptoms. They'll notice redness or pink color, or sometimes they get patients that send me messages because it's different colors from fuchsia to purple every hour of the day. And I'm like, baby, you don't need to look as much at your it but um But basically, you know if you have symptoms, definitely look, talk to your doctor, but it's good to look even if you don't have symptoms. you know And if you've never looked at your vulva before, we have so many colleagues that are really pushing those, you know check your vulva once a month, especially you know if you're over 50 or 60, but definitely if you have symptoms.
00:05:42
Speaker
Yeah, that is interesting. And I know not everybody's comfortable even looking at themselves. Sometimes during exams when I have patients, I'm like, okay, do you want to see that? Absolutely not. I don't want to see, but there's a merit in at least knowing what's there. Like if we could see the inside of our bodies, I don't know, maybe I'm just a nerd. I would love to see what different organs would look like. But you can see your vulva without any extra equipment other than a mirror. And I'll say we have them like children's books that are like my inside your outside machine, you know, about a whole looking at our body and like you said, the inside of your bodies. But I definitely think if you're listening to this podcast, and you've never looked at your vulva, I would say today, let's try take a look. Right? Because then also, you don't know if there is a change, right? So say someone has
00:06:26
Speaker
burning, itching, they feel a lump or a bump. They don't know if that's a change from their normal of how things look if they've never seen what normal is for them, right? And that's what we're looking for when people come in and they have symptoms. We're like, okay, has it always been like this? What did it look like before? How long has this been there? And so you actually really help us too if you are a little familiar with how you look.
00:06:48
Speaker
you know When should somebody be worried? When should someone say, OK, I've got to bypass my GP or really push for a recommendation from my GP and try to get in to see someone like you?
00:06:59
Speaker
I think starting with the person that will look at your vulva. So whether that is your GP, your gynecologist, your dermatologist, I do think that my patients, a lot of them fall in this black box of they're getting regular skin checks by their dermatologist. But historically, dermatologists will say, okay, let's take off everything but your bra and underwear and get ready for the doctor.
00:07:22
Speaker
One of my young medical students who is really passionate about this work too pulled up a study from 2019 and they surveyed people who went into dermatology offices and 84% of them were expected to have a vulvar exam or a genital exam, but maybe not everyone is actually getting that genital exam. So I would say, you know, definitely anyone that will look. I think a lot of gynecologists are seeing patients regularly for cervical cancer screening, but they don't always spend a lot of time on the vulva either. So I think, you know, talking to somebody about it, I think if you have seen multiple doctors and you still haven't gotten an answer about things, that's when I would reach out to look for someone that has some specialty in, you know, genital disease.
00:08:04
Speaker
Yeah. And that's a great point, right? So if your primary care person or your gynecologist isn't looking and your dermatologist is also not looking and you're not looking, we're all in the dark, right?
00:08:17
Speaker
so Because somebody should be examining you, especially if you have symptoms, somebody has has got to look. And even, like, what about for
Importance of Regular Vulvar Checks
00:08:26
Speaker
melanoma? That's something, you know, I have to get skin screening once a year because of family history. But people with strong family histories of melanoma, should they also be having their vulvas examined? Absolutely, absolutely. And what's really sad is even now in 2024, and Some of my friends, Chris and Iris Wollnoff have looked at this extensively. It's just the morbidity and mortality for vulva vaginal melanoma is horrific. The five-year mortality is so much higher than other cutaneous melanomas. And I really think it's because we're not looking enough.
00:09:00
Speaker
not, you know, no one is looking enough at this area. So I mean, my personal goal, honestly, I have, I know we all have lots of soapboxes, but one of them is in 10 or 15 years, you won't have to go to a specialist because all of us will be very well versed and feel comfortable looking. And we're going to disseminate information and education out there that, you know, we can look, identify and treat. No, sorry i'll i'll I'll dial that back a little bit This is my new shtick that like until the system changes, like we have to educate ourselves to learn how to navigate the system. And so it kind of led me to thinking, all right, so if you are a senior dermatologist or you're a senior gynecologist, and no one's really looking at your vulva or answering your questions about your vulva, you may actually have to advocate for yourself and say,
00:09:48
Speaker
Hey, would you mind looking at my vulva to make sure that this looks normal or that there's no other signs of, you know, really anything else that you might be there for, right? Yeah. And for men, like, you know, when I'm doing skin exams, I you know see patients in the hospital and in clinic and in the hospital, we do a lot of pre-organ transplant skin checks. Cause if someone has a skin cancer, we want to make sure that we identify it before they're immunosuppressed and go on a medicine that can cause their risk of skin cancer to go higher.
00:10:15
Speaker
But with women, you know, I look at the vulva, I spread the labia majora and look at the labia minora and the enteritis. And men, we retract the foreskin. We can also see the glands, you know, but I mean, I think that's the level of detail that if someone hasn't looked at you like that, for instance, and you have a history of melanoma somewhere else on your body, today's the day. Take a look at your vulva. You know, if you see something dark, it's definitely something to bring up. And there's plenty of things on our vulva that look different, that are normal. So things like angiocaratomas,
00:10:43
Speaker
Our little 1 to 2 millimeter papules, they look dark. They look scary. They can bleed. And so that's the best concern for melanoma vulva patient that I've ever seen is when people actually have angiocaratomas and they're not that. You can also have vulvar melanosis. So there's some you know darker pigment changes that happen. but if there's like a very you know dark black spot or really anything that you're worried about when you look at your vulva, bring it up with your doctor the next time you see them. you know Anything changing, growing, painful, or anything that you're just you haven't noticed before, that's when I'd want you to bring that up to a doctor. Yeah. and I feel like what it comes back to is that your vulva isn't just another body part.
00:11:25
Speaker
So like it's like your elbow. Yes, right. Like if you had something on your elbow are on your nose and you noticed it because it was itching and then you wouldn't just see somebody about it and they'd say, Oh, how long has it been there? Like, I don't know. I've never, I've never looked at my elbow. I've never looked at my nose. Right? Yeah. I told you about the problem that I wrote if your mobile were on your face.
00:11:46
Speaker
I love that. I know. I like talked to my patients about that because they're like, but I think things are getting smaller. I was like, let's duck about this. This stack, these stack, everything in here gets pushed up. And my friend wrote a poem that I really need to get a copy of because I'm going to put it on the show notes in case anybody has not seen it. We literally spread people's toe webs because people have a history of, and so in every skin exam, we're taught to spread the webs of your toes, looking for, you know, looks in every creak of your ear. And so again, we should be looking between the labia majora, you know, the perineum, the perianal skin and having it be a systematic way of incorporating it into our skin exams.
00:12:27
Speaker
Again, I think right now, before maybe even
Seeking Specialist Care for Vulvar Issues
00:12:30
Speaker
two years ago, I was only doing all of our exams on my skin patients, my regular annual skin checks, like maybe 90% of the time. I think in the last year, I've been really good about 100% of the time, unless a patient declines. But and I try to tell them, you know even if you don't feel comfortable today, let's talk about it in the future because you can get melanoma down there too. And it's important for us to take a look.
00:12:50
Speaker
Yeah, no, that's great. Tell me a little bit more about like in sclerosis, because that's another area of your specialization. And I did have Dr. Jill Kraft on at some point earlier this year. And so she kind of dove into the depths of like in sclerosis, which was wonderful. But what do you see in the office? Are people coming in because they already have that diagnosis or because they have symptoms? Like, what do you most commonly see when like in sclerosis comes up for your patients?
00:13:14
Speaker
I will say that I kind of see the the whole gamut. So I have probably 10% of my patients have not seen a doctor and have really severe symptoms and also have severe clinical signs. That's about 10%. And that population with lichen sclerosis, which is, you know, a chronic T cell mediated disease that we can see scarring, architecture change, we can see those clinical disease signs and then all people also have some That's 10%. That is the population I more often see things like skin cancer in as well. I will say skin cancer and lichen sclerosis, it's less than 5% of patients that we see. More often, so the 90% of people I see with lichen sclerosis have already seen a doctor two or four before they see me, but when they are diagnosed with that, whether by biopsy or clinical exam,
00:14:06
Speaker
They're told to use a topical steroid. They're scared shitless of using that topical steroid because the way you pick it up from the pharmacy, the pharmacist is like, oh, if I were you, I wouldn't put that anywhere near my genitals. And then their family practice doctor also says that. And then, you know, it's reinforced on social media. So, I mean, I feel like all the messaging is kind of all over the place. And so they're scared. And so I think part of our job has been get them in, do a good exam. I think a lot of people have mild clinical signs.
00:14:33
Speaker
of their disease because that clobetazole or the topical steroid helps mediate that or you know decrease the clinical signs. But some of these people have had this going on for years and years and years. And so they have severe architecture changes without the matching severe clinical signs.
00:14:51
Speaker
And so again, this is another thing that I hope in 10 or 15 years, we'll understand more about the mechanics of this condition. So people can recognize it early, get on maintenance therapy to prevent that architecture change. Because we have big studies now showing us that maintenance therapy one to three times a week of a topical steroid can prevent those architecture changes.
00:15:11
Speaker
I mean, I really think we can move the bar forward because right now we're seeing after effects of people getting this diagnosis 20 years ago, but not getting the information maybe, or not understanding who to get the information from maybe. and Again, this has changed. That paper came out in 2015.
00:15:28
Speaker
So I think that we're understanding this disease better. We have a book that came out recently on lichen sclerosis that's free online for everyone. I think it's great. Free information to kind of move you know our understanding of this disease to a different place. No, that's wonderful. Okay, question for you because this is what my patients ask me and I want to know what you tell people.
00:15:52
Speaker
when people say, but I shouldn't use the steroid on my skin because it's going to cause skin thinning, right? This is like one of my favorite questions. You know, we all have our favorite questions. I said, okay, so when you use the right amount in the right place, like we talk about, the only side effect you're going to get is we're going to prevent your itching. We're going to prevent architecture changes and decrease your your chance of getting skin cancer.
00:16:13
Speaker
So if you use
Safe Use of Topical Steroids and Biopsy Benefits
00:16:14
Speaker
a month worth, which most people come in, I asked them to show me how much they're using. A lot of times they're using two to four weeks of medicine with every application. If you use that, it will thin your skin and you'll get increased phalangec pages and other things. But I'm like, use this much.
00:16:27
Speaker
the right place, the right amount, the right frequency, side effects are what we want. We want this to not be driving your life. Exactly. Exactly. Okay. I love it. Thanks. I just, I'm just curious. you tell people Sometimes I tell them, okay, well, if this scarring is thickening your skin, you're not really and at risk of fit things becoming too thin, right? But I like, I like combining what you're saying as well. The only other question I wanted to ask you is, The patient needs a biopsy, what should they be expecting? Because I do find people who are nervous about having a biopsy of their vulva compared to any other part of their body. I think it's very nerve wracking anytime do anything on the vulva. In general, it's an office procedure.
00:17:12
Speaker
So it takes much longer actually to set up than it does to to do the procedure. I personally use local numbing agent before I do an injectable numbing agent. That sometimes can take the edge off of things. I think that's a lot of different ways to to do biopsies. I've been told that mine don't hurt as much as other people's, which I try to tell them to. No, I think that as long as you're open and your provider wants to do that, I think having that discussion and letting them know if you're nervous,
00:17:41
Speaker
you know, sometimes if people are really nervous, they're not ready, have them come back, you know, and I think you being in control of your body and having that agency, but definitely come back if someone's worried about something if you go. Yeah. But basically, there's lots of different types of biopsies we do on the vulva. Skin cancer, I typically am doing a punch biopsy, which it looks like a little cookie cutter.
00:18:02
Speaker
take a little piece about that big. And I use either gel foam or a suture to help close that hole because I think it feels a lot faster than just leaving it open. But the vulva does heal really, really, really well. There's another type of modified shave we do that's not as deep when I'm trying to diagnose other skin conditions. It's a lot more scary, I think, just thinking about doing a biopsy there than other places and for good reason. Definitely something to to be open about if your provider you know talks to you about it and just because they want to do a biopsy doesn't mean it's always going to be skin cancer that they find. so Exactly that's exactly what I was going to say and and not to be nervous for that because sometimes it's just confirmation of a diagnosis which is really hugely helpful because I think most of us would love to see the same physicians forever or you know advanced practice providers forever but people change and you end up having to
00:18:53
Speaker
relocate or your providers change. And so having a confirmed diagnosis is super helpful. Yeah, basically for for things like lichens, chlorosis, when people see me, they either get a photo or a biopsy. And so like that's just part of their like medical record moving forward, but also for them to keep a copy of.
00:19:11
Speaker
Because if we catch these things early enough, then there aren't architecture changes. We can get their vulva looking like it was before they noticed any color or texture change. And so when they see a new doctor, they may be like, didn't you really have that? I'm not sure. And so it's good to have one of the two.
00:19:29
Speaker
No, I think your work is awesome. And I'm so glad that you're doing this in Texas. And if people are looking for a welfare dermatologist and they don't live in Dallas, where would you direct them to go? Lots of projects on the horizon about that question. But I will say there's lots of organizations. I think Lycan Squares to Support Network is a great resource for people. I will say on their website, some people are listed, but they don't actually see patients anymore because they're retired or whatnot. But we have lots of societies. I think that ISSVD is great.
00:19:59
Speaker
IshWish is great, a vulvar derm, research consortium great. I mean, I think just even Googling, you know, vulvar specialists, and you'll get a lot of names near you, but there's a lot of, a lot of people around. And again, in 10 or 15 years, I really hope that almost everyone will be comfortable, you know, seeing, recognizing, diagnosing these conditions. I'm curious. Where do you refer people? someone i I have a hard time. I mean, if I know, it's really through like, what I know.
00:20:27
Speaker
You know, sometimes we'll talk to you like, do you know anybody in Los Angeles? I think that's the other thing is like reaching out to your colleagues, right? or very Absolutely. Hard. It's hard if you're not plugged in somewhere and or if you have no idea where to get started. That is hard. It would be great if ISSVD has had to find a provider.
00:20:45
Speaker
directory the way IshWish does. You could look at IshWish because there's a lot of overlap between the two societies. So you may be able to find somebody who really has good vulvar knowledge and expertise through the IshWish finder provider site. I love that. Well, this has been wonderful. Thank you so much for all of this information. Lovely to have you here. And I know there are so many other topics that we can talk about. This has been a really great start. So thank you so much for your time, Dr. Muskar. Thanks for having me.