Click here to view next page of this article

 

New Treatments for Labial Adhesions 

The labia majora and minora require estrogen to maintain their normal tissue tone. In a low-estrogen environment, the labia can fibrose in response to even the slightest trauma or inflammation. This fibrosis can lead to labial adhesions after an irritation such as a diaper rash. The labia minora fuse in the midline, leaving a fine line best demonstrated on physical examination by gently retracting the labia majora upward and outward. In a low estrogenic state, adhesions can occur anytime after the first few weeks of life until puberty but rarely occur in older women except in very hypoestrogenic labia adhesion.

Medical Treatment

Local medical treatment of labial adhesions consists of an application of estrogen. A topical estrogen cream (Premarin; Estrace) is applied with a very small urethral swab, painting the cream just on the line of the labial adhesion.

Some girls respond readily, but others may need topical estrogen until puberty. The dosing schedule is twice a day for 2 weeks and once a day thereafter. Monthly office visits are recommended initially, and additional follow-up depends on the rate of improvement.

The more estrogen absorbed, the greater the potential to stimulate other estrogen-responsive tissue, such as the breasts. Secondary physiologic findings can cause parental anxiety but regress.

New Estrogen Delivery Agents

A useful new therapeutic alternative for labial adhesions is the transdermal estrogen skin patch (Climara, FemPatch, Alora, Vivelle, Estraderm). These patches involve less effort than topical estrogen cream application. The drug is equally distributed throughout the patch matrix and can be cut with scissors.

Estraderm patches can't be cut. A strip of estrogen patch should be applied as close as possible to the labial adhesion. Because this condition seems to predominate among girls with sensitive skin in the first place, a trial of different formulations for the best personal response is appropriate (Climara, FemPatch, changed weekly; Alora, Vivelle.

Many expect the endpoint of therapy to be the initial separation of the labia and stop estrogen application patches as soon as this happens. In fact, the labia in the early stages of separation are still raw and inflamed.

The PCP can avoid this and the consequent loss of parental confidence by initially educating parents to expect to maintain topical estrogen therapy for a minimum of a month after resolution of the adhesions. Thereafter, the estrogen is replaced by a bland ointment (A+D Ointment, Balmex, Desitin) while closely observing for adhesion recurrence over several months or until the offending agent, such as diapers, is no longer an issue. If at any point the adhesions begin to recur, resumption of estrogen therapy.

Surgical Approach

Poor response to several months of appropriate medical therapy, not poor compliance, is the indication for surgical intervention. In recalcitrant cases, manual lysis of adhesions is necessary. Lysing labial adhesions is a simple procedure and may be performed in the office by the PCP or, if general anesthesia is required, by any provider with operative privileges for children.

Because labial adhesions resolve with the hormonal changes of puberty, ignoring the condition entirely is an option with an asymptomatic child and parental concurrence.

As with treatment of genital warts, children can find this experience traumatic if they are aware but unable to communicate. Misperception of treatment as iatrogenic sexual assault can occur.