Podcast Episode 18: Vulval and Vaginal Health with Dr Caroline Owen
On this episode of the Newson Health Menopause Society podcast, host Lauren Redfern is joined by Consultant Dermatologist with a special interest in vulval disease, Dr Caroline Owen. Along with clarifying when the terms ‘vulva’ and ‘vagina’ should be used, Caroline outlines what a healthy vulva should look like, providing advice and guidance on self-examination and how to spot markers of concern. Caroline takes time to outline the effects of a number of different conditions that can affect our vulval health. In particular, she discusses the impact of Lichen sclerosus – a chronic inflammatory skin disorder that can prove particularly disruptive during the perimenopause and menopause. Explaining the ways in which the condition can affect the lives of its sufferers, Caroline highlights the need for continued research into the condition. This episode asks us to get comfortable with our anatomy and provides important insight into how we can all be advocates of our own anatomy.
Caroline is a member of the British Society for the Study of Vulval Disease and is also responsible for chairing the British Association of Dermatologists Education Group Vulval workstream. She has co-authored material for the postgraduate curriculum on vulval disease, the post-CCT fellowship in vulval disease and the recently updated national vulval service standards.
Lauren Redfern [00:00:06] Welcome to the podcast for the Newson Health Menopause Society, a multidisciplinary collective of interested professionals passionate about improving hormone health across the world. The society exists to educate and inspire others to raise the standard of menopause care and access to treatment, to facilitate research collaborations across specialties and countries, and to provide expert advice and guidance to our associates. The ultimate aim of the Newson Health Menopause Society is to improve the lives and future health of women and all who experience the perimenopause and menopause. I’m Lauren Redfern. I’m a medical anthropologist and I’ve been exploring the experiences of those using testosterone as part of their HRT treatment. In this podcast series, I’m going to be talking to guests from a variety of different disciplines in order to share knowledge and ultimately improve our understanding of the perimenopause and menopause.
Lauren Redfern [00:01:05] Whilst perimenopausal and menopausal symptoms such as vaginal dryness or vulval pain may sound somewhat manageable, their occurrence can in fact have a significant and at times devastating impact on the lives of many. In her early forties, Alison describes feeling bewildered when she found herself suffering from a string of seemingly untreatable UTIs, vaginal burning and intense vulval pain. She describes needing to carry a vaginal moisturiser with her wherever she went and feeling at a complete loss of what to do. Alison highlights how, when her symptoms started, she simply didn’t consider the perimenopause as a possibility. She felt she was too young, and this was an assumption that was echoed by her GP. Alison’s symptoms continued, and all the while she describes having no idea that they could have been related to low levels of estrogen. She explains how after her first episode of cystitis, she went on an eight month round the houses with NHS services, including multiple courses of antibiotics, referrals to urology, gynaecology and physiotherapy for pelvic floor therapy. She even decided to pay privately to see a vulval pain specialist because she was in so much discomfort. After some research, Alison did become aware that her symptoms could be related to the perimenopause and menopause, and eventually she paid to see a private menopause clinic due to difficulties communicating with her GP. Alison is feeling a lot better now but describes how her specific symptoms were excruciating. She had to leave work because the pain she was experiencing was so severe. Alison says it breaks her heart to think about the estimated 2.4 million women currently living in the UK with vulva pain and how she feels frustrated knowing there is more that we could do. Joining me today on the podcast to discuss the important topic of our vulval health is consultant dermatologist Dr Caroline Owen. Caroline has a special interest in vulval disease and has published widely in this area. She’s also recently updated the National Vulval Service Standards. Hi, Caroline, thank you so much for joining me on the podcast today. If we could just start with you introducing yourself to those listening and telling us a little bit more about the work that you do.
Dr Caroline Owen [00:03:13] Hi, Lauren. Thank you very much for inviting me. Yes, so my name is Dr Caroline Owen. I’m a consultant dermatologist and I work for the NHS at East Lancashire Hospitals NHS Trust, which is in the north west of England. I’ve always been interested in vulval disease and I’ve had a specialist vulval clinic for almost 20 years now. I’m also a longstanding member of the BSSVD, which is the British Society for the Study of Vulval Disease and if people aren’t aware of that organisation, it’s really great and I would encourage you to go and have a look and maybe join and see what we do. I’m education lead at the moment for the BSSVD and I also chair the vulva workstream of the British College of Dermatology, which forms part of the British Association of Dermatologists.
Lauren Redfern [00:03:57] That’s great. One of the first things I actually wanted to address, it’s a pet peeve of mine, and it might sound a bit straightforward, but I think sometimes I hear a lot misconceptions and confusion around people using the word vagina when they mean vulva. And I wondered if we could just clarify for those listening what those differences are and when we should be using which particular term.
Dr Caroline Owen [00:04:20] I think that’s a really great question to start with, because I think they often are used interchangeably, incorrectly. And so I think it’s really essential for all healthcare professionals to be able to communicate accurately when describing anatomy. And actually for all of us as women, it’s important that we know the proper name for our anatomy as well. So basically the vulva is the part of the female genitalia that is on the outside, that you can see. So there’s the mons pubis at the front and then you have the labia majora, which are the larger hair-bearing lips, and then you have the smaller inner lips, the labia minora, which are non-hair-bearing and very sensitive. And then at the top there’s the clitoris. And actually the part of the clitoris that people see is actually just the clitoral bulb. So the clitoris is larger than people realise. It’s a sort of wishbone shape like an inverted V and the clitoral bulb sits at the top and it’s covered by the clitoral hood or the clitoral prepuce. And then there are the arms of the clitoris that extend down either side of the vaginal canal. Between the labia minora, you have the vestibule or the introitus and within that, you have the vaginal opening and just above that, the urethral orifice, which is where the wee comes out. At the bottom of the vagina, you have the posterior fourchette, which is often very fragile with a lot of conditions that affect the vulva, that often can split and be very uncomfortable. And then between the anus and the fourchette, you have the perineum and it’s the perineum that can sometimes be damaged during childbirth. And then the vagina is the elastic, muscular canal with a flexible folded lining that connects the uterus to the vulva.
Lauren Redfern [00:06:00] That’s great. And I wondered also, I suppose with that clarification, if we could spend actually a bit of time talking about what a healthy vulva looks like and what we should be conscious of looking out for. You know, I guess also how we can check our own vulvas to ensure that they are healthy too.
Dr Caroline Owen [00:06:17] That’s a really great thing to talk about because I think it’s…not many people really know what a vulva looks like because there isn’t very much opportunity to examine anybody else’s other than your own. And even, I mean I see lots of women in my clinic who haven’t even examined their own. And I suppose the first thing to say is that everybody’s different. So everyone’s vulva is different just as everyone’s face is different. The labia minora particularly, I think people become anxious about the labia minora because they’re not kind of quite sure what they should look like. They do take quite a long time to develop, and they often develop asymmetrically and that’s completely normal. They often protrude slightly beyond the labia majora, and that is completely normal. They’re often a dark pink or brown colour and that is completely normal. And it is normal also in the vulva to have a few little lumps or bumps sometimes. So there are sometimes little collections of blood vessels called angiokeratomas. Sometimes you can get little inclusion cysts called sebaceous cysts. Sometimes people worry when they look at the sort of bottom of the vagina and they see the natural folds of the vagina and they think they are looking at a lump and it’s not, it’s just their own normal anatomy. If anybody wants to know what a normal vulva looks like, then there is a really great resource called the Labia Library. So all you need to do is just Google ‘Labia Library’ and click on that and you’ll see 24 photographs of labia with photographs taken from the front and from underneath. And then I’m sure many listeners will have heard about the Great Wall of Vagina, which is actually a great wall of vulvas, and that is 400 casts of vulvas by an artist called Jamie McCartney, who was concerned about this terrible sort of trend for labiaplasty – so women sort of having surgery to alter the shape of their labia to achieve some kind of idea of ‘normal’. There’s really no clinical benefit to labiaplasty. It’s being marketed as ‘female empowerment’, but really it’s just trading on women’s insecurities. So I think it’s on display in Portugal at the moment, but you can have a look at it online, I’m sure.
Dr Caroline Owen [00:08:17] So in terms of what to watch out for, really anything that’s new or uncomfortable or sore or itchy, anything that feels raw or rough and in terms of lumps or bumps, anything that’s new or changing. Really basically anything that you’re not sure about, it’s the same advice really that we would give to anybody who’s sort of, you know, checking out their skin if they’ve got a mole that they think might be changing. Obviously, we would advise them to go and have that checked out as well. So anything that you’re not sure about, it’s worth having it checked out. In terms of what to do to keep the vulva healthy. You really don’t need to do very much at all, and I would generally say less is more. So just washing once a day with water is fine. You don’t need any harsh soaps, you certainly don’t need any deodorants. We really advise that you don’t remove the pubic hair, although it’s quite hard to convince people of that these days. But if people do want to remove the pubic hair, then definitely no hair removing creams because that really sort of damages the lipid layer of the skin because if you think about it, it’s dissolving the hairs and so it’s dissolving the lipid layer within the skin as well. Waxing, I think well, it’s not a good idea because that’s pulling the hairs out from the root. And you can get lots of problems with ingrown hairs then and what’s called pseudofolliculitis. So obviously a razor on the vulval skin isn’t ideal either. So if you do need to remove the pubic hair, then just trimming with scissors is really all that’s required. And I suppose the other thing that is really important to mention in terms of vulval health is making sure that you don’t have urinary incontinence because it really isn’t good for the vulva to be in contact with urine or with damp pads. And that is something that I do see quite a lot in my clinic. And it’s really important for healthcare professionals to ask about incontinence because women often don’t volunteer that information. And even if you say, ‘do you have urinary incontinence?’ And people will say ‘no’. But if you say, ‘well, do you leak if you cough or sneeze or do you have to dash to get to the loo in time, or does a little bit escape before you get to the loo in time?’ Then often you do realise that it’s more common than often people realise. A bland moisturiser is probably all you need, particularly if you suffer from dry skin. So people who need to moisturise their hands and face, particularly if you’re prone to eczema, you may need to moisturise the vulva, but you don’t really normally need to put anything on.
Lauren Redfern [00:10:32] And can I ask you on that, Caroline, in terms of coming into contact with urine there like, what is the issue with that? If the vulva is coming into contact with urine in that way, what can that cause?
Dr Caroline Owen [00:10:41] So I suppose it’s a bit like getting a nappy rash really. So it’s like a baby sitting in a damp nappy. People know what a nappy rash looks like, so it causes what’s called an irritant contact dermatitis. So I think it actually increases the pH of the environment, which isn’t good and can predispose to urinary tract infection because it can alter the sort of natural flora. And I think it also increases what’s called the frictional coefficient, so more like the skin becomes more fragile as well. So we do also know that there’s a definite association between urinary incontinence and lichen sclerosus, but I think we’re going to come on to talk about that.
Lauren Redfern [00:11:19] Yeah, absolutely. I wanted to ask as well what symptoms could indicate that a patient would be suffering with vulval issues? And how can that, I guess, commonly be missed or even misdiagnosed?
Dr Caroline Owen [00:11:32] So the kind of symptoms that patients may present with include itching, soreness, dryness, dyspareunia, which is painful intercourse, fissuring which are little paper cuts, bleeding. I think the problem with vulval symptoms is that they are often really non-specific and can be associated with many different vulval conditions. So it is easy for conditions to be either missed or misdiagnosed because there is so much overlap. And I think sometimes people struggle to know whether their symptoms are coming from the vulva or the vagina as well, partly because of the issue that we talked about with people not being quite sure about their anatomy. But also there is some overlap in terms of innervation. So sometimes it can be quite difficult to localise where pain is coming from. So I do worry – I mean, obviously a lot of people now talking about vaginal dryness, but I do worry that often people are actually describing vulval symptoms rather than just vaginal symptoms. And so I think that’s really important for people to be aware of. And the other important thing is that there is often more than one diagnosis. So when someone has vulval symptoms, it doesn’t mean that there’s just one thing going on. So for example, I often see eczema and thrush together and I often see genital urinary syndrome of menopause and lichen sclerosus together. And it’s really important to recognise that they can coexist and to treat both of them.
Lauren Redfern [00:12:52] And I’m wondering, when it comes to the relationship between the perimenopause and menopause and our vulval health, really how and why are hormones – or the lack of them – affect our vulval health, like what’s happening in that relationship?
Dr Caroline Owen [00:13:05] Well, the vulva’s definitely affected by the menopause and all of our skin ages with time. We’re all very familiar with that. So that’s chronological, ageing and some areas of skin also have ultraviolet damage. So the front of your arm probably looks older than the under surface of your arm because that’s had more sun over the years. But estrogen deficiency in the vulva certainly accelerates the ageing process and the tissues become smoother and paler. There’s reduced labial thickness, so the labia minor shrink and they can sort of become stuck down. There’s generally reduced collagen and elasticity and the vaginal mucosa becomes more fragile. There’s reduced subcutaneous fat in the mons pubis and in the labia majora. The pubic hair tends to become thinner. You sometimes see a retraction of the clitoral hood as well. So the clitoral bulb can be a little bit more exposed and that can cause tenderness. And it can also cause reduced pelvic floor strength and control, reduced bladder capacity and sensation. So there is an association with urinary incontinence and urinary symptoms as well. So in terms of symptoms, people may develop dryness, reduced lubrication with sex, burning, itching, and then urinary frequency and urgency, because there are estrogen receptors in the vulva, the vagina, the urethra and the bladder. And previously we sort of recognised, or we called this urogenital or vulval atrophy or post-menopausal atrophy, but it’s now been renamed Genitourinary Syndrome of Menopause, which I think is good in a way, because obviously it means that we’re very aware that the urinary symptoms can be part of it. And that is, you know, obviously a really important part to treat. But I think it’s also important that we don’t shy away from naming the anatomy as well.
Lauren Redfern [00:14:53] Absolutely.
Dr Caroline Owen [00:14:54] So Genitourinary Syndrome of Menopause is usually progressive and it’s not entirely reversible. And there is a safe and effective treatment in the form of topical estrogens. And I think in dermatology we’ve been a bit slow to recognise GSM really. Five years ago, I moved my clinic into the gynaecology department in my Trust, which has been absolutely fantastic because I now work alongside gynaecologists, urogynaecologists, specialist nurses, specialist midwives, women’s health physios, and I’ve learnt so much by working alongside them. And one of the first things I noticed was how much estrogen they were prescribing. And so I’ve become much more confident about using estrogen and have realised that it can help in many conditions. And I often in perimenopausal and menopausal women, I’ll now prescribe that alongside the treatment for whatever sort of dermatological condition women have. And if I’ve learnt anything in the last 20 years it’s that there definitely is often more than one diagnosis. So it is really important to make sure that we are treating Genitourinary Syndrome of Menopause alongside these other conditions.
Lauren Redfern [00:15:57] Yeah, absolutely. I want to come back to you mentioned earlier that you have experience obviously working with lichen sclerosus. And I wondered if we could spend some time just discussing what this is and what the symptoms are. And I suppose if untreated, what the complications can be as well with untreated lichen sclerosus.
Dr Caroline Owen [00:16:18] Well, it’s a really important topic, so I’m really grateful to have a bit of time to discuss it.
Lauren Redfern [00:16:22] Yeah, absolutely.
Dr Caroline Owen [00:16:23] Lichen sclerosus is a long term inflammatory condition, which affects predominantly the genital skin. It can affect both sexes, but it’s more common in women and I think it’s more common than people realise. So there are estimates that it affects one in 60 women and one in 900 girls and it tends to start in … there are two main age groups. So it’s girls before puberty and women around and after the menopause. The inflammation causes damage to the skin, and if untreated, it can lead to loss of the normal architecture and anatomy of the vulva with scarring and narrowing of the introitus. So it can cause really devastating consequences. And we also know that there is an association with vulval cancer, particularly if it isn’t diagnosed and treated. We don’t really understand fully what causes it. We know that there is an association with autoimmune conditions such as thyroid disease, and we think there’s probably a genetic predisposition and we know now that there is a link with urinary incontinence. So I did a study with my colleagues in Nottingham which showed that women with lichen sclerosus were two and a half times more likely to have urinary incontinence than women presenting with other vulval conditions. And there must be a hormonal component because of the ages that it affects women. But really that hasn’t yet been sort of fully researched or understood. So there is much more that we need to learn about it. In terms of the symptoms that it presents with, it causes a really intense itch, just an absolutely miserable itch that keeps people awake at night and can really be unbearable. It also causes pain, soreness, painful sex, fragility, splitting, and the signs that you see – which is why it’s so important to examine these women when they present with these symptoms – a whitening, often with a wrinkled or atrophic appearance, fissuring, bleeding under the skin and then loss of normal architecture. So the labia minora often become completely stuck down or disappear completely. And you can have complete fusion over the clitoral hood as well. So sometimes you just really get left with just a really narrow opening to the vagina and that’s all you can see. I mean, in really severe cases, it can sort of almost close up completely. So even passing urine becomes difficult.
Lauren Redfern [00:18:40] Wow. Okay.
Dr Caroline Owen [00:18:41] In terms of treatment, it’s really quite straightforward as long as it’s recognised and caught early and the treatment is a super potent topical steroid and it has to be applied regularly. So we start off by using a super potent steroid every day for a month, and then we gradually reduce it down every other day. And then as long as symptoms are controlled, we use it twice-weekly, long term. But it’s really important that women and healthcare professionals appreciate that lichen sclerosus is a long term condition and it does need long term treatment. In the past, we used to say that once your symptoms had gone, you didn’t need to treat it and you only needed to treat it if your symptoms came back. But now we know that it is a long term condition and it is really important to keep going with treatment. But that is really hard to persuade people to do, particularly if they’re not having any symptoms. So obviously I have talked about steroid being the main treatment for lichen sclerosus, and we do have to spend a lot of time reassuring people about using topical steroids because there is a lot of anxiety out there about topical steroids. And in general in dermatology, we spend a lot of our time reassuring people because we do use topical steroids in all sorts of dermatological conditions. And one of the problems is that the summary of product characteristics, which come when people have these treatments dispensed in the package, there’s an insert which contains information about the product that’s going to be used. And in there it’ll say, don’t apply to the genital area and don’t apply for more than seven days. In children it says, don’t apply for more than five days. And so we have to spend a lot of time reassuring patients that they have to ignore that information, which is just so frustrating. And I know that Dr Newson is lobbying the MHRA because of the information that’s contained in the SPCs around topical estrogens as well. And I do have to reassure patients about that as well, because there’s so much misinformation generally out there that we don’t want misinformation being contained in products that we’re prescribing. So if lichen sclerosus is diagnosed and treated early and effectively, it can be really well controlled and really doesn’t have to cause any problems long term. But the problem is that some women can’t get a diagnosis because they haven’t sort of managed to see the right healthcare professional. And I’ve seen some really sad cases over the years of patients whose relationships may have broken down or who’ve been unable to conceive, or they’ve sought help and they haven’t been able to access the care that they need. And lichen sclerosus, if untreated, can lead to really severe scarring and even cancer of the vulva. So it’s just so important that these women are seen and examined and treated and looked after long term. And there are so many pressures in the NHS at the moment, it just seems to be getting harder and harder. And one of my colleagues, Sophie Rees, who works in Bristol, has done a brilliant piece of qualitative research recently looking at the impact lichen sclerosus has on women. And it’s just been published in the British Journal of Dermatology, and three main themes emerged. The first was missed opportunities, so participants experienced delayed diagnosis, lack of information and disempowering encounters with healthcare professionals. The second was learning to live with a long term condition. So the amount of work involved in learning how to manage the disease and the impact on everyday life. And the third I thought was really sad, it was a secret life. So the experiences of the condition were often shrouded in secrecy and there was stigma associated with having a vulval skin condition which resulted in them feeling really isolated and lonely. And it’s just a really powerful paper. And there were some really sad but sort of powerful stories, so I would really encourage people to have a read of that. And I feel that there are some really obvious parallels with where menopause care was a few years ago, and no one really wants to talk about vulval disease because it is surrounded by feelings of shame and stigma. And I think this tidal wave of menopause awareness is just absolutely fantastic. And now everyone can say hot flushes and perimenopause and brain fog and vaginal dryness and no one bats an eyelid. But still, you know, vulval disease hasn’t quite got there yet. And I would just really like the same thing to happen really, the same revolution to happen in vulval care.
Dr Caroline Owen [00:22:51] Yeah, absolutely. And something I know we’ve discussed is the need, you know, you mentioned some research there that’s been carried out and that’s great but something we have discussed is the need for more research to be undertaken looking at vulval health. And I wondered if we could spend some time discussing this and really what needs to be prioritised in research and why that is.
Dr Caroline Owen [00:23:12] Yeah, I think it’s so important because it is such an under-researched area and women’s health in general is under-researched. And I think you’re right that vulval disease has been particularly neglected. And I think maybe part of the reason for that is that it has historically belonged in several camps. And that’s why the BSSVD is so great, because it’s multidisciplinary. And so it tries to bring these healthcare professionals together. Vulval disease can present to dermatologists, gynaecologists, genitourinary specialists, sexual health, incontinence specialists. So I think because it can sort of fall between those stools and maybe that’s one of the reasons why, but I think another reason is the shame and stigma that still exists. And so we do need to break down those barriers.
Dr Caroline Owen [00:23:55] I think the recently published Women’s Health Strategy for England is really welcome and this is identified that much more needs to be done for women’s health generally and has identified that there’s not enough focus placed on women specific issues and that women are underrepresented when it comes to important clinical trials. So I think, you know, they have set out this ten year strategy to improve the health of women everywhere, and it does include plans to increase female participation in research. And one of the things it also mentions is to have women’s health hubs so that women’s healthcare can be sort of coordinated in one location. And I think it’s really important that we make vulval disease part of that. So there is work that’s being done. Rosalind Simpson’s team in Nottingham, she’s doing some fantastic work. She’s led the priority setting partnership for lichen sclerosus, which has identified the main sort of research priorities for lichen sclerosus. The UK Dermatology Clinical Trials Network has had genital dermatoses as its main focus, this year’s main topic for 2022. And the Wellbeing of Women organisation also funds a lot of women’s health research. So there is work out there going on, which is fantastic, but there is much more that needs to be done.
Lauren Redfern [00:25:13] Yeah, and I feel like a part of that is probably, you know, how education is important and how that contributes to raising awareness both among the general public and healthcare professionals. And I’m curious to hear, you know, what you feel needs to be prioritised within education when it comes to our knowledge and understanding of vulval vaginal health.
Dr Caroline Owen [00:25:34] So I think one of the things that we tend to do in medicine to cope with complexity is that we do specialise and then subspecialise, which is great and it is really great for the patients who get as far as the specialists. Certainly with BSSVD and with the British College of Dermatology, we have worked to put together a programme to make sure that we are training vulval specialists. So there’s the advanced training skills module for gynaecology trainees who want to develop a vulval interest. And we’ve also developed a post-CCT fellowship for dermatology trainees who want to develop an interest in vulval disease. But the problem is that it’s just so hard for women sometimes to access these services. And one of the reasons why we wanted to develop the updated guidelines for ‘[Standards of] Care with patients with Vulval Conditions’ is to try and develop a sort of network and pathway really, so that women can get to the care that they need. But that also means that we have to upskill the healthcare professionals who are seeing these women at the first point of contact. And so this is really what we’re trying to focus on now, is to try and educate the healthcare professionals who these women are first presenting to. And there are lots of those people. So obviously general practice, menopause specialists, advanced nurse practitioners, practice nurses, women’s health physios, incontinence nurses. So there are lots of people out there who have an opportunity to see these women. So every time a woman goes for a smear, for example, there is an opportunity there to have the vulva examined and there is an opportunity there for women to sort of say if they’re having vulval symptoms. So I think we’re just really keen now to try and get some education out to those professionals who are seeing these women when they first present. And we really want to try and make people understand that any skin condition can affect the vulva, that symptoms are often non-specific and that there is often more than one diagnosis. And I think the other really important message is that you can’t really make a diagnosis without looking. And also, if you’re not sure what’s going on, that’s absolutely fine. But make sure that you do refer people on if you’re not sure, so that they can access the care that they need.
Lauren Redfern [00:27:50] No, absolutely. I think sadly, that’s actually all we’ve got time to discuss, which is a shame, because I feel like I could continue asking a million different questions on this, this really important topic. I want to thank you for joining me. And I like to end these podcasts really by asking our guests if they have any take-home messages they would like to stress really when that comes to the topic that we’ve talked about. Yes. So what you would take-home would be.
Dr Caroline Owen [00:28:11] Well, thank you, Lauren. So my three take-home messages are number one: so the vulva is part of your body, get to know it, get to understand it, appreciate it and look after it. My second is, if you have vulval symptoms, seek advice and make sure that you’re examined. Don’t accept vulval symptoms or vaginal symptoms or urinary symptoms as a normal part of ageing because they definitely aren’t. And to all the healthcare professionals, be aware that there are many conditions that can affect the vulva and there is often more than one diagnosis. Examine everyone who has symptoms. It doesn’t have to be on the same day. I know that primary care is under immense pressure so it doesn’t have to be on the same day but make a plan to examine these women if they have vulval symptoms. Treat what you recognise and refer on if you’re not sure.
Lauren Redfern [00:29:00] Yeah, that’s great. Well, thank you so much for joining me and I’ll chat to you again soon.
Dr Caroline Owen [00:29:04] Thank you so much, Lauren.
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