Treatment of Labial Fusion With Topical Estrogen Therapy

Summary:

Twenty girls with labial fusion that covered at least 50% of the vaginal opening were treated with a topical estrogen cream. The cream was precisely applied to the fused area twice a day until the adhesions were totally lysed. After separation of the adhesions, a petroleum ointment (Vaseline) was applied twice a day to the labia minora for at least 1 month. The introital area was carefully rinsed twice each day before application of either the estrogen cream or the petroleum ointment. The mean age of the studied population was 13.2 months (range, 2 to 38 months). The mean duration of estrogen treatment was 2.4 months (range, 1 to 3.5 months). All patients were successfully treated. Five patients developed vulval pigmentation, which lasted for a mean of 1.5 months. One patient developed breast enlargement, which lasted for 1 month. The mean duration of follow- up was 3.1 months, and there was no recurrence of labial fusion during the period of follow-up. We conclude that treatment of labial fusion with topical estrogen therapy is safe and effective. Clin Pediatr. 2005;44:245-247

Introduction

Labial fusion refers to partial or complete adherence of the labia minora.1 Other names for this condition are vulvae fusion, atresia of the vulva, synechia of the vulva, occlusion of the vestibule, atresia vulvae superficialis, adhesion of the labia minora, and agglutination of the labia minora.2,3 Labial fusion predisposes to asymptomatic bacteriuria and urinary tract infection.4-6 Rarely, the labial fusion is so nearly complete as to cause urinary outflow obstruction with resultant bladder distention or hydronephrosis.7,8 Parental anxiety about the problem can be considerable. Topical estrogen therapy is the treatment of choice.1,9,10 We report our experience with the use of a topical estrogen cream in the treatment of 20 patients whose labial fusion covered at least 50% of the vaginal opening.

Methods

Girls with labial fusion who were assessed at an ambulatory care clinic in Calgary, Alberta, Canada, between February 2002 and May 2004 were recruited into the study. Patients were included in the study if the fusion covered at least 50% of the vaginal opening and were excluded if they had been treated in the past for this condition. Parents were advised to apply an estrogen cream (Premarin cream, Wyeth-Ayerst) precisely to the area of fusion twice a day until the adhesion totally resolved. After separation of the labia minora, the parents were advised to apply a petroleum ointment (Vaseline) twice a day to the labia minora for at least 1 month. The families were advised to carefully rinse the introital area twice a day before application of either the estrogen cream or the petroleum ointment. The parents were requested to bring the child back for assessment twice a month during treatment and for the 4 months following resolution of the labial fusion. During treatment and follow-up, the parents were questioned and the child was examined for possible adverse events including vulval pigmentation and breast enlargement. Persistence of adverse events and recurrence of labial fusion were assessed at each follow-up visit.

Results

There were 20 girls in the study. The mean age of the patients was 13.2 months (range, 2 to 38 months). The mean duration of estrogen treatment was 2.4 months (range, 1 to 3.5 months). There was no treatment failure. Vulval pigmentation was noted in 5 patients and breast enlargement in 1 patient. No other adverse events were noted. The mean duration of follow-up after resolution of the labia fusion was 3.1 months (range, 2.5 to 4 months). Vulval pigmentation lasted for a mean of 1.5 months (range, 1 to 2 months). The breast enlargement lasted for 1 month. There was no recurrence of labial fusion during follow-up.

Discussion

Labial fusion is most commonly noted between 3 months and 4 years of age and has a peak incidence of 3.3% between 13 months and 23 months of age.11 Labial fusion is considered to be an acquired condition secondary to hypoestrogenism and vulvovaginitis.1,12,13 Since labial fusion rarely persists beyond puberty, some investigators do not recommend treatment of asymptomatic labial fusion.14,15 We recommend treatment since stagnation of urine behind the fused labia might lead to asymptomatic bacteriuria and urinary tract infection.5,6 Currently, topical estrogen therapy is the preferred treatment.

There is no clear consensus for the duration of treatment with topical estrogen therapy. Sanfilippo10 reported that 1 week of treatment was effective in more than 90% of cases. Opipari16 suggested treatment with topical estrogen for 4 to 12 weeks. Capraro and Greenberg2 treated 50 patients with labial fusion with a topical estrogen cream. Of 47 patients with adequate follow-up, 42 (89%) had good results after 2 to 4 weeks of therapy. Aribarg12 treated 25 girls with severe adhesion of the labia minora. Topical estrogen therapy was successful within a month in 22 (88%) patients. In those successfully treated, the duration of treatment was 1 week in 8 (36%) patients, 2 weeks in 10 (45%) patients, 3 weeks in 3 (14%) patients, and 4 weeks in 1 (5%) patient. Khanam et al17 treated 50 girls with labial fusion with topical estrogen cream for 2 to 8 weeks. Forty five (90%) responded to treatment.

Some authors recommend manual separation if the labia remain fused after 2 weeks of topical therapy.18,19 Murann19 performed a retrospective chart review of 259 girls with symptomatic labial fusion referred to a Pediatrie and Adolescent Gynecology Clinic. The girls were treated with topical estrogen therapy for 10 to 14 days. The fused labia resolved in only 121 (47%) patients. One hundred and thirty-eight girls who did not respond to topical therapy had their labial adhesions separated in the office under topical anesthesia. The procedure was successful in 112 patients. The remaining 26 patients required surgical separation of the labia minora under general anesthesia. This study by Muram19 reported an especially low success rate with topical estrogen therapy. A variety of reasons might account for this low success rate. Topical estrogen therapy was used for only 10 to 14 days. It is possible that the success rate might have been greater with a longer duration of treatment. Not mentioned is whether the author counseled the families on the importance of meticulous introital hygiene. Careful genital hygiene likely minimizes the inflammation, which is important in the pathogenesis of labial fusion. We recommend that the introital area be rinsed twice each day before application of the topical estrogen cream and after any bowel movement or soaked diaper. The patients in the study reported by Muram19 were assessed at a tertiary care clinic at the University of Tennessee. This highly selected population included many girls with dense, fibrous adhesions. As such, the studied population might not be representative of patients assessed in a general pediatrie or family practice setting. In our study, the success rate was 100% after a mean duration of estrogen treatment of 2.4 months. We do not recommend or resort to mechanical separation of the labia minora, which can he physically and emotionally traumatic.1,2

Some authors are reluctant to use topical estrogen therapy for more than 8 weeks because of the risk of an adverse event.18 Of the 25 patients treated by Aribarg,12 slight vulval pigmentation occurred in all patients, but the pigmentation disappeared after the medication was discontinued. The duration of treatment varied from 1 to 8 weeks. Of the 50 patients treated for 2 to 4 weeks with topical estrogen therapy by Capraro and Greenberg,2 3 developed vulval pigmentation, 3 complained of breast tenderness, and 1 manifested both adverse events. The adverse events disappeared after topical estrogen therapy was discontinued.2 Bacon9 performed a retrospective chart review on 23 patients with labial fusion who had been treated with topical estrogen therapy. Treatment regimens varied widely in duration because of practitioner individuality and patient tolerance. Four patients had vulval erythema and pain, and 2 had breast “budding.” These adverse events disappeared after the topical estrogen therapy was discontinued. Increased body hair was noted in 1 of the 2 patients who developed breast “budding.” The body hair partially resolved after the topical estrogen therapy was discontinued. In our study, 5 patients developed vulval pigmentation, which lasted for a mean of 1.5 months. One patient developed breast enlargement, which lasted for 1 month. None of our patients developed increased body hair. None of our patients or any of those reported in the literature developed vaginal bleeding during or subsequent to topical estrogen therapy. The adverse events from topical estrogen therapy are usually mild and resolve with the cessation of the treatment. To minimize the possibility of an adverse event, we recommend that only a small amount of estrogen cream be precisely applied to the fused area.1 In our experience, the use of topical estrogen cream is safe for the treatment of labial fusion.

Recurrence of labial fusion is reported to be common. In the retrospective study by Muram,19 recurr\ence developed in 14 (11.6%) of 121 patients treated with topical estrogen cream, 18 (16%) of 112 patients treated with manual separation of the labia, and 4 (15.4%) of 26 patients treated with surgical separation of the labia under general anaesthesia. We did not encounter any recurrence during the period of follow-up. The absence of recurrence might be related to our emphasis on the importance of meticulous introital hygiene to minimize inflammation and to the application of a petroleum ointment for at least 1 month after separation to minimize readhesion. Another explanation might be our small sample size and the relatively short duration of followup (mean, 3.1 months).

Acknowledgment

The authors would like to thank Ms. Vivian Shiao for expert secretarial assistance and Mr. Sulakhan Chopra of the University of Calgary Medical Library for help in the preparation of the manuscript.

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Alexander K. C. Leung, MBBS, FRCPC, FRCP, FRCPCH1,2

W. Lane M. Robson, MD, FRCPC3

C. Pion Kao, MD, FRCPC1,2

Edmond K. H. Liu, MBBCh2

Justine H. S. Fong, MD2

1 Department of Pediatrics, the University of Calgary; the 2 Asian Medical Centre, an affiliate with the University of Calgary Medical Clinic, Calgary, Alberta, Canada; and the 3 Department of Pediatric Urology, the University of Oklahoma. Oklahoma City, Oklahoma, USA.

Reprint requests and correspondence to: Dr. Alexander K. C. Leung, #200, 233-16th Avenue NW, Calgary, Alberta T2M OH5, Canada.

2005 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, MY 11545, U.S.A.

Copyright Westminster Publications, Inc. Apr 2005