Objective The aim of the study was to determine how experts treat vulvar high-grade squamous intraepithelial neoplasia (VHSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). Method A 26-question survey was designed through a literature review, reviewed by the Survey Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), and distributed to all ISSVD members via e-mail in January 2019. Results Overall, 90 of 441 physician members consented to participate and 78 of 90 were eligible to complete the survey. Most respondents were gynecologists (77%), followed by dermatologists (12%). Forty-five percent responded that their pathology was being reported using the 2015 ISSVD terminology of vulvar squamous intraepithelial lesions. The most common first-line treatments were as follows: unifocal VHSIL—excision (65%), multifocal VHSIL—imiquimod 5% (45%), VHSIL in a hair-bearing area—excision (69%), and clitoral disease—imiquimod 5% (47%). In the recurrent VHSIL, excision was favored (28%), followed by imiquimod 5% (26%) and laser (19%). Differentiated vulvar intraepithelial neoplasia was most often first treated with excision (82%), and more patients were referred to gynecologic oncology. Most patients were seen in follow-up at 3 months (range: 1 week–6 months). Sixty-seven respondents provided 26 different ways to follow treated patients, which were most commonly every 6 months for 2 years and then yearly (25%), followed by every 6 months indefinitely (18%). Conclusions Treatment of VHSIL and dVIN varies among vulvar experts with excision being the most common treatment, except in multifocal VHSIL where imiquimod is commonly used. There is wide variation in how patients are followed after treatment.

Menopause is now considered as a mid-life event. Hormone replacement therapy (HRT) is justified when menopausal symptoms adversely affect the quality of life of the individual woman. Management of unscheduled bleeding with HRT remains a clinical challenge and leads to pressure on resources. The aim should be to exclude endometrial pathology and to regulate the bleeding pattern so that the woman's concerns are addressed and compliance maintained. The mechanisms which underlie this unscheduled bleeding are poorly understood. Appropriate counselling should be offered at the outset. Learning objectivesTo gain knowledge of the most appropriate HRT regimens used in perimenopausal, postmenopausal and hysterectomised women to minimise unscheduled bleeding. To learn how to tailor the treatment regimen to the individual woman's situation. Ethical issuesThe lack of clinical evidence for managing unscheduled bleeding should be acknowledged. Should clinicians initiate expensive and invasive investigations in all women with unscheduled bleeding on HRT or only select those with significant risk factors?

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