Lichen Sclerosus, Menopause & the Microbiome
Lichen sclerosus (LS) is often managed as a local inflammatory skin condition, with topical corticosteroids forming the cornerstone of treatment for many.
But emerging research is pushing us to think more broadly.
A recent study examining gut, vaginal, and skin microbiomes in peri- and postmenopausal women with vulvar lichen sclerosus (VLS) suggests that LS may reflect a multi-system microbial imbalance, not just a localised skin issue (Ma et al., 2024).
In recent years LS has been explored more from the microbiome angle which is excellent news for those experiencing the condition. This paper is the first I have seen that looks at three different microbiomes in LS patients. So it is definitely worth reading,
For both practitioners and patients, understanding the microbiomes opens up a more integrative, layered approach to care.
Menopause impacts LS risk
LS has a clear clinical pattern:
It often emerges or worsens in low-estrogen states and stages of life (childhood, lactation, menopause, some OCP users)
We know that estrogen has many important roles some of which include microbiome regulation.
Estrogen helps regulate:
- Vaginal glycogen (fuel for Lactobacillus)
- Mucosal immunity
- Tissue integrity
- Gut microbiome composition
When estrogen declines, we see a shift in microbial ecosystems, particularly across the gut–vagina–skin axis.
A Three-Site Story: Gut, Vagina, Skin
What makes this study compelling is its multi-site lens. Lichen sclerosus is understudied and we haven’t really seen it being explored in the literature as a microbiome disorder. Human health is complex, but there are several key factors that point to this lens being important.
Gut: a systemic inflammatory driver
The in the study people with LS showed:
- Altered microbial diversity in the gut microbiome
- Increased taxa associated with inflammation (e.g. Sphingobium, Gemella)
This supports the idea that the gut may influence immune tone and inflammatory signalling beyond the intestine and that LS has autoimmune associations.
Skin (Vulva): local dysbiosis
On the vulvar skin they found:
- ↑ Prevotella, Streptococcus, Parabacteroides
- ↓ Corynebacterium
These shifts are consistent with:
- Barrier disruption
- Immune activation
- A more inflammatory local environment
Vaginal microbiome: an interesting and complex signal
The study reports:
- Reduced diversity in LS
- Changes in taxa including Blautia and Lachnospiraceae
At first glance, this might be framed as “loss of beneficial microbes.” However, this doesn’t fully align with what we understand about vaginal ecology and I had to re-read the study a number of times to understand why these results differed so much from the typical discussions on the vaginal microbiome I encounter.
- A healthy vaginal microbiome is typically:
- Low diversity
- Lactobacillus-dominant
- Higher diversity is often associated with dysbiosis (e.g. Bacterial Vaginosis and Aerobic vaginitis)
So what’s going on here?
One important consideration is population context.
- More diverse vaginal microbiome states (e.g. CST IV) can exist in a healthy population
- CSTIV is more commonly observed in certain ethnic populations, including East Asian cohorts
So the patterns seen in this study may reflect:
- A different “baseline” microbial ecology for an asian population
- Rather than a simple healthy vs unhealthy population
It highlights two key points:
- These findings are interesting, but not directly generalisable
- Repeating this research in ethnically diverse populations would likely provide deeper insight
For now, the takeaway is not that LS is driven by “loss of butyrate producers” or “low diversity,” but rather:
The vaginal ecosystem in LS appears altered, but the meaning of that alteration is context-dependent.
Mechanisms: How Microbiome Changes May Drive LS
Despite some nuances, the broader mechanistic picture is intriguing.
1. Loss of microbial regulation
Changes across gut and vaginal microbiota may reduce:
- Anti-inflammatory signalling
- Barrier support
- Immune modulation
2. Immune activation
Certain bacteria identified in LS:
- Can evade immune clearance
- Or promote inflammatory pathways (e.g. Th1 signalling)
This aligns with the autoimmune-like features seen in LS.
3. Oxidative stress and metabolic dysfunction
The study identified alterations in:
- Glutathione metabolism
- Pentose phosphate pathway
- Amino acid metabolism
Suggesting:
- Increased oxidative stress
- Impaired tissue repair
- Altered cellular resilience
What This Means for Clinical Practice
Topical corticosteroids are still required
They:
- Control inflammation
- Prevent disease progression
- Reduce long-term complications
But they don’t address:
- Microbial imbalance
- Systemic inflammation
- Tissue resilience
A Holistic Approach: Working Alongside Standard Care
At Intimate Ecology we consider a holistic approach not as an alternative, but as a complement.
1. Support the gut microbiome
- Increase dietary diversity
- Focus on fibre and polyphenols
- Consider targeted interventions where appropriate
2. Restore vaginal ecology
- Support Lactobacillus dominance (where relevant)
- Address dryness and pH
- Consider collaboration with GPs around local estrogen therapy
3. Reduce inflammatory load
- Nutritional support for antioxidant pathways
- Stress and sleep regulation
- Identify triggers and irritants
LS may be expressed locally, but it is influenced systemically. Testing and supporting multiple microbiomes may improve:
- Symptom control
- Flare frequency
- Overall tissue resilience
This study is small and exploratory. But it does something important which we haven’t seen before in research. An encouraging move in the management and understanding of LS. It moves LS from a local skin condition, to a multi-system, microbiome-influenced inflammatory state. And while some findings, particularly in the vaginal microbiome require cautious interpretation, they still point in a valuable direction.
Need support?
If you’d like help navigating this, working with a clinician can make a significant difference.
We can help you:
- Order and interpret your microbiome results
- Understand systemic and environmental influences on your symptom flares
- Find a soothing and supportive approach that considers you and your reactivity
- Work with your hormonal state and stage of life
Book an appointment with an Intimate Ecology practitioner here
And if you’d like to go deeper, you can explore some of our Instagram posts on this topic.
- Lichen sclerosus and autoimmunity: View instagram post here
- Lichen sclerosus and menopause: View instagram post here
- I’m too young to have tearing: View instagram post here
- Hormonal contraceptives and the vaginal microbiome: View instagram post here
- What is that itch? View instagram post here
References:
Ma, X., Wen, G., Zhao, Z., Lu, L., Li, T., Gao, N., & Han, G. (2024). Alternations in the human skin, gut and vaginal microbiomes in perimenopausal or postmenopausal Vulvar lichen sclerosus. Scientific Reports, 14(1), 8429. https://www.nature.com/articles/s41598-024-58983-y