Vulvar SCC is a cancer that is frequently diagnosed late in UK primary care — the average time from first symptom to diagnosis is approximately 12-15 months, and a significant proportion of this delay occurs at the GP stage through repeated empirical treatment without biopsy. The two main pathways to vulvar SCC: (1) HPV-related pathway (typically younger women, associated with high-grade VIN, HPV 16/18, cigarette smoking) and (2) Non-HPV pathway (older women, arising on background of lichen sclerosus, lichen planus, or differentiated VIN — the latter being easily missed because it resembles reactive changes). The key GP principle: any vulvar lesion in a postmenopausal woman that has not resolved with 3-4 weeks of appropriate treatment (including a presumed contact dermatitis or candidal infection) must be referred for biopsy. The GP should have a very low threshold for 2WW referral in any postmenopausal woman with vulvar symptoms, particularly: white or red plaques, persistent ulcers, nodules, bleeding, or pain not responding to treatment.

Lichen sclerosus is the most important vulvar condition for GPs to diagnose and manage correctly because: (1) it affects approximately 1 in 30 postmenopausal women (and also occurs in premenopausal and paediatric patients); (2) it is frequently misdiagnosed as candidal infection or contact dermatitis and treated empirically for months to years without the correct diagnosis; (3) untreated or inadequately treated LS leads to progressive architectural destruction (labial fusion, clitoral phimosis, introital stenosis) which is irreversible; and (4) it carries a 5% lifetime risk of vulvar SCC, which risk is substantially higher in undertreated disease. The diagnosis is clinical in most cases — the figure-of-8 distribution (vulva + perianal skin) of white atrophic shiny skin with purpura (subepidermal haemorrhage from fragile vessels) is pathognomonic. Biopsy is required for: atypical presentations, resistance to treatment, any suspicious lesion, or to confirm diagnosis before long-term potent steroid therapy. NICE recommends that any GP who is uncertain about the diagnosis of a vulvar condition should refer to gynaecology or a specialist vulvar clinic rather than treating empirically.

The Q-tip test for vulvodynia/vestibulodynia is a simple, standardised bedside examination that every GP should be able to perform — it is performed by gently touching a moistened cotton-tipped swab (Q-tip) sequentially to the vulvar vestibule at the positions of a clock face, asking the patient to rate pain (0-10) at each touch. In vestibulodynia (provoked vestibulodynia/PVD), the posterior vestibule (5, 6, and 7 o'clock positions — near the hymenal ring) produces intense pain (typically 7-10/10) with the gentlest touch, while the same touch is painless or mildly uncomfortable on the labia or non-vestibular skin. This focal provoked allodynia (pain from a non-painful stimulus) is diagnostic of vestibulodynia and is distinct from the diffuse tenderness of vulvodynia. The test takes 2 minutes and guides management — positive Q-tip test at the posterior vestibule = vestibulodynia, which responds to pelvic floor physiotherapy, low-dose amitriptyline, and psychosexual therapy; diffuse unprovoked vulvar pain = generalised vulvodynia, which has a different management pathway.

Recurrent vulvovaginal candidiasis (RVVC) is a clinically frustrating condition affecting approximately 6-8% of women — the management requires systematic investigation (confirming the diagnosis microbiologically, identifying the Candida species, and excluding underlying predisposing conditions) before starting long-term maintenance therapy. The commonest error is prescribing repeated short courses of fluconazole without ever confirming the species. Candida glabrata accounts for approximately 15% of RVVC and is inherently less susceptible to fluconazole (higher MIC) — women who fail standard fluconazole treatment should have the species confirmed. The FSRH 2020 guideline recommends: induction therapy with fluconazole 150 mg every 72h for 3 doses, followed by maintenance with fluconazole 150 mg weekly for 6 months. At the end of 6 months, approximately 90% of women achieve remission, but relapse occurs in approximately 50% on stopping — this should be discussed with the patient at the outset.

The specialist vulvar clinic is an underutilised resource in UK primary care — it is a multidisciplinary clinic typically staffed by a vulvar dermatologist or gynaecologist with an interest in vulvar disease, sometimes supported by a pelvic floor physiotherapist and a specialist nurse. These clinics provide: expert biopsy, dermoscopy, treatment of lichen sclerosus/planus to prevent malignant transformation, management of vulvodynia, and liaison with psychosexual therapy. Many women with chronic vulvar conditions are managed in primary care for years with repeated candida treatments, steroid creams, or antifungals without ever having an adequate examination, biopsy, or specialist input. GPs should have a low threshold for referring to a specialist vulvar clinic for any vulvar condition that has not been clearly diagnosed or is not responding to appropriate treatment within 3 months.

The clobetasol application technique for lichen sclerosus is one of the most practically important educational points at diagnosis — studies consistently show that patients under-apply topical corticosteroids to the vulva because they are worried about steroid side effects, using only a small amount of cream. The correct amount for the entire vulva and perianal area is approximately 0.5g per application (half a fingertip unit), applied as a thin film to all affected skin including the perianal area. Under-application is the most common reason for inadequate treatment response in LS. The GP should provide clear written instructions and ideally demonstrate with a diagram at the first prescription. Common patient concerns to address: (1) thinning of the skin — paradoxically, adequate clobetasol treatment thickens and restores the atrophic LS skin toward normal; it is the LS itself (if untreated) that causes skin atrophy; (2) absorption effects — the total weekly dose used in LS maintenance (typically 0.5-1g/week) is far below the dose that causes systemic corticosteroid effects.

The Word catheter insertion for Bartholin abscess is a GP-performable office procedure that can prevent a hospital admission — the technique: (1) adequate analgesia (LA infiltration of the labial skin with lidocaine 1-2%; optional Entonox if significant patient anxiety); (2) #11 scalpel blade inserted at the medial aspect of the labium minus at the 4 or 8 o'clock position (medial surface, not the labial skin surface — this avoids scarring visible from outside); (3) 0.5 cm stab incision; (4) digital exploration and drainage of abscess contents; (5) Word catheter (or Foley catheter with 12-16F balloon) inserted and balloon inflated with 2-3 mL of water; (6) catheter tip tucked into vagina for comfort. The catheter is left in situ for 4-6 weeks to allow epithelialisation of a permanent new duct. The patient should be told she can continue normal activities with the catheter in place. GP training in this procedure is available through FSRH workshops and the RCGP practical procedures training programme.

The GSM (genitourinary syndrome of menopause) treatment conversation is one of the most impactful interventions at menopause consultations — a condition affecting approximately 50% of postmenopausal women, causing vaginal dryness, dyspareunia, urinary urgency, and recurrent UTIs, that is almost universally treatable with local vaginal oestrogen (Vagifem 10 mcg pessary, Ovestin cream, or imvexxy). Unlike vasomotor symptoms (hot flushes) which often improve over time, GSM is progressive without oestrogen — the vaginal mucosa atrophies further with each year after menopause. Despite its high prevalence and treatability, only approximately 25% of affected women receive treatment, primarily because: (1) women are too embarrassed to mention symptoms; (2) GPs do not proactively ask; (3) women (and some GPs) believe GSM is normal ageing and cannot be treated; and (4) women worry about local oestrogen being 'hormones' with cancer risk. Local vaginal oestrogen at the recommended doses (Vagifem 10 mcg) produces negligible systemic oestrogen absorption and is considered safe for virtually all women, including most women on aromatase inhibitors for breast cancer (the ASCEND trial, 2024, confirmed safety in this group).

The photographic documentation of lichen sclerosus architectural changes at annual review is a quality standard that protects both the patient and the GP — progressive fusion of the labia minora, clitoral phimosis, or introital stenosis that is not documented or acted upon represents a missed opportunity to prevent irreversible structural damage. Serial clinical photographs (with patient consent) allow comparison year-on-year and justify escalation of treatment or specialist referral when progression is documented. In the absence of photography, a detailed written description (e.g., 'bilateral labial minora reduced to approximately 50% of normal size, clitoral hood beginning to adhere to glans, introital calibre approximately 2 finger breadths') provides baseline documentation. GPs who review LS patients annually without recording the degree of architectural change have inadequate documentation.