Introduction
Vulvar lichen sclerosus (VLS) can be diagnosed clinically or with a biopsy. While a clinical diagnosis involves minimal pain, in that at most, your clinician will look at the skin and maybe move the skin around a bit, a vulvar biopsy can be painful. It can also be scary. So, to help mitigate some of the fear and pain that some folks experience, we wanted to put together a post with tips and tricks to help make the process as comfortable as possible. This will involve things you can do before, during, and after the biopsy.
If you want a quick downloadable checklist with condensed tips and tricks, click here.
Disclaimers
*This post comes from lived experience from our VLS community and does not constitute medical advice.
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Is a Biopsy Necessary, and What Does a Vulvar Biopsy Involve?
Krapf et al. (2020) note a biopsy is not necessary when the clinical picture is clear and the clinician is confident in the diagnosis. A clinical picture is what your doctor sees and the symptoms you have. If your symptoms and what they see on your vulva indicate a clear. However, if the clinical picture is not clear and the clinician is not sure about the diagnosis, or if they suspect any pre-cancer or cancer, they may do a biopsy to confirm (Krapf et al., 2020).
Most guidelines and medical organizations agree. For example, the British guidelines for managing LS recommend a biopsy to confirm LS. That said, they note that vulvar biopsies are not always practical nor essential to diagnose (McCarthy et al., 2019). The Royal College of Obstetrics and Gynecology Greentop 2011 guidelines note a biopsy is not necessary if a clinical diagnosis; the UK National Guideline from the British Association for Sexual Health and HIV (2014) agrees (ibid).
Regarding biopsies for VLS, a punch biopsy is the gold standard. This is because VLS is a ‘skin-deep’ condition. That is, it affects all the layers of our skin–the epidermis (top layers), the dermis (middle layers), and the hypodermis (bottom layer). If your clinician does a shave biopsy, removing only a small part of the epidermis, it is not enough for the pathologist (the specialist reading the biopsy sample) to determine if VLS is present. A bunch biopsy gives the pathologist enough information to make a diagnosis.
What Does a Punch Biopsy Involve
A punch biopsy is performed with a sharp, circular, hand-held instrument that removes a small, round piece of tissue – approximately 4mm across. Doctors will follow different protocols for the punch biopsy. Often, your doctor will first inject you with a local anesthetic to numb the vulvar tissue, and then, once you are numb, they will do the punch biopsy and remove a
sample of your tissue. That initial numbing needle can cause a great amount of pain. Compassionate doctors will use a topical numbing cream (e.g., Emla cream) before they inject the anesthetic – this can reduce the pain from the needle.
Read on for ways to make this process less painful.
What Can You Do Before Your Biopsy?
Believe it or not, there are many things you can do before a biopsy to set things up for success.
First, there are some important things to discuss with your clinician; ask your doctor,
- How many biopsies they plan on taking, where they will take them, and why?
- This can help you have a clear expectation of what will happen. For example, knowing you will have two instead of one biopsy and knowing why they need more than one may put your head at ease.
- Will you prescribe pain medication? If so, can you prescribe it so I can pick it up before the procedure?
- This way, when the biopsy is done, you can head straight home instead of taking a trip to the pharmacy and waiting for your meds to fill.
- Ask if they will use a topical numbing cream before they inject you with the anesthetic.
- This is important. The needle with the anesthetic is what hurts the most. This pain can be reduced if topical numbing cream is applied to the vulva before the injection. If they do not, ask if you can pick up an over-the-counter numbing cream like Emla cream and apply it beforehand.
- Ask for an aftercare sheet and have them or a nurse review it if you have questions.
You may also want to buy some things in advance to make recovery as smooth as possible.
For example, you may want to purchase:
- A soft cushion or donut pillow to sit on to take pressure off of the vulva and pelvis as you recover,
- Private packs or cold packs to help reduce pain, itch, and inflammation,
- A Peri Bottle,
- Barrier cream (e.g., Vaseline–ask your doctor for recommendations)
- 2-3 days’ worth of super loose and comfy clothing and underwear
- Bleach-free/fragrance-free menstrual pads (there can be some bleeding the day of and a few days after).
- Quick, ready-made comfort meals or someone to take care of you post-biopsy (Jaclyn likes ready-made lasagnas, mac n’ cheese, soups, protein shakes, and a nice stash of snacks).
You may want to arrange for someone to drive you home (either a friend or reserve an Uber).
Things to do During Your Biopsy
Feeling scared and nervous on the day of your procedure is normal and OK. This isn’t easy, and many of us go in symptomatic and have years of medical trauma and gaslighting under our belts, further complicating the procedure. Here are some things to practice/consider on the day of your procedure to help alleviate pain and fear:
- Communicate with the healthcare team about your nerves and see if they can do anything to reassure you,
- If you need a clear explanation of each step, ask for this.
- Bring headphones and try listening to some soothing music or a gentle podcast to distract you. Let your healthcare team know you will wear them for anxiety; you may need to keep the volume low or keep one earbud out so you can still hear and communicate with them.
- Bring a support person (if allowed)
- Remember, you have the right to ask for a break or pause. If things are overwhelming, say, “I’m feeling overwhelmed and just need a minute to breathe.” Then, practice deep breathing and let them know when you can continue.
- Confirm your lift (friend, family, Uber) to bring you home.
- Practice deep, diaphragmatic breathing (breathing slowly and deeply into the belly and pelvis) in the waiting room and during the procedure.
Things to pack:
- Emla or numbing cream if you need to purchase it independently (ask the pharmacist for the best time to apply it).
- A water bottle
- Snacks
- A book, phone, kindle, and headphones (basically, something to help distract you)
- A fidget toy (if that helps you with stress)
- A stress ball to hold during the procedure
After Your Biopsy
Be gentle with yourself after your biopsy and during recovery. We all have different pain thresholds and heal at different rates.
If possible, take 2-3 days to rest and heal.
Be sure to:
- Take any pain medication as prescribed,
- Follow your aftercare sheet and any instructions from your healthcare provider,
- Use a cold compress or ice pack to help with pain, itch, and inflammation,
- Keep the biopsy site clean by washing it with water in the shower and keeping it dry during recovery,
- When peeing,
- Use a peri bottle to clean the vulva after instead of toilet paper
- Apply a barrier cream if clear from your healthcare provider
- Get plenty of rest (now is the time to start on that ever-growing Netflix list of shows and movies you’ve been building up),
- Keep everything handy and close by so you don’t have to get up often,
- I (Jaclyn) like to make a mini fort around my bed–I have comfy socks and clothes next to the bed, water bottles, a drawer of snacks, my medication, etc.
- Stay hydrated
- Avoid sexual activity and moderate-intense exercise until the area is healed.
- Practice self-love and community care (connect with your support resources).
Conclusion on Vulvar Biopsy Tips and Tricks to Manage Pain and Fear
In sum, navigating a vulvar biopsy can be a daunting experience, but with the right preparation and support, it can be made much more manageable. Remember, you’re not alone in this journey. Many have walked this path before and have shared their insights to help you feel more at ease.
By preparing beforehand, communicating openly with your healthcare team, and practicing self-care during and after the procedure, you can reduce the stress and discomfort associated with a vulvar biopsy. Don’t hesitate to ask questions, seek support, and take the necessary steps to ensure your comfort and well-being.
We hope this guide has provided valuable tips and tricks to make your biopsy experience as comfortable as possible. If you found this post helpful, please support our mission to provide important education like this. Whether through donations, volunteering, or sharing our posts within your support groups, your support helps us continue to offer guidance and reassurance to those in need
Remember, you are strong, and you’ve got this! Take care of yourself, and don’t hesitate to reach out to your community for support.
Sources Cited
Krapf, Jill M., et al. “Vulvar lichen sclerosus: current perspectives.” International journal of women’s health (2020): 11-20.
McCarthy, Siobhan, et al. “Should we always biopsy in clinically evident lichen sclerosus?.” Journal of Lower Genital Tract Disease 23.2 (2019): 182-183.
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