Background: Vulvovaginal atrophy affects approximately 45% of middle-aged women, as a result of decreased estrogen circulating levels and is often associated with vulvovaginal discomfort in menopausal patients. The spectrum of adverse consequences makes long-term treatment essential, not only for symptom relief, but also to avoid further complications. These symptoms can even be worsened if other vulvar conditions coexist, such as inflammatory dermatoses. Clinical presentation: We present two cases of patients with severe vulvar atrophy and craurosis, who required vulvo-vaginal opening associated with medical treatment. In both patients, we diagnosed severe genitourinary syndrome of menopause (GSM) complicated by vulvar lichen sclerosus, a very rare clinical situation. In case 1, the symptoms had progressed despite local estrogen treatment for vulvovaginal atrophy, and lichen wasn’t considered in previous check-ups. In contrast, patient nº 2 presented in the ER with impossibility to urinate and was then diagnosed and treated for underlying causes. Conclusions: GSM treatment should be a priority. The absence of improvement or progression of genital atrophy should alert the specialist to the coexistence of other vulvar pathologies.

Introduction and Hypothesis:Vaginal pessaries are used as a conservative treatment for POP in women who do not want or are not candidates for surgery, or as a preliminary step to surgery. Our goals are:· Evaluate the evolution of patients with advanced POP and repeated expulsion of the pessary, who underwent perineal suture to try to maintain the device.· Describe the epidemiological characteristics of patients treated with pessaries in our environment, with or without perineal closure.Methods:Observational, descriptive and prospective study (October 2016-March 2021) that includes 352 women with advanced-stage POP treated with a pessary, of which 55, after repeated expulsion of the pessary, were treated with a pessary and perineal suture.Results:After pessary insertion associated with perineal closure, 26 patients (47.2%) expelled the pessary and underwent surgery, and 29 (52.8%) kept the device, avoiding surgery.Regarding the women who required perineal suture:The mean age was higher than in the group of patients who did not need this intervention (75.3 vs. 68.3 years), 94.5% had POP ≥ grade III and 100% had a perineal width >2.5cm. Conclusions:· Treatment with pessary and perineal closure avoids surgery in women with advanced age and repeated expulsion.· Although age should not be an independent factor that limits surgical treatment or the type of intervention, it would be useful to have scales to quantify the frailty of patients, being able to standardize perineal closure in elderly and/or frail women, and in those who do not want or have contraindications for surgery.