History of present illness: A 62-year-old gravida 4, para 4 woman presents to her gynecologist complaining of new itching and irritation of her vulva. The patient reports noticing multiple “bumps” approximately 10 months earlier but thought this could be normal in menopause. She is sexually active with one male partner and does not use condoms. She has not seen a gynecologist in many years but notes a remote history of chlamydia, and has a history of multiple abnormal Pap tests in the past with “multiple biopsies” done. Her past medical history is notable for chronic hypertension controlled on an angiotensin-converting enzyme (ACE) inhibitor. The patient denies alcohol or illicit drug use, but does report a 1 pack per day smoking history for 40 years. Physical examination General appearance: Thin woman in no acute distress Vital signs: Temperature: 36.8°C Pulse: 86 beats/min Blood pressure: 120/82 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 99% on room air BMI: 21 kg/m HEENT: Unremarkable Neck: Supple Cardiovascular: Regular rate, regular rhythm without rubs, murmurs, or gallops Lungs: Clear to auscultation bilaterally Abdomen: Soft, nontender, nondistended, active bowel sounds present Rectal: Normal tone, no masses, brown stool Pelvic: External genitalia revealed flat, rough white lesions on the left labia measuring 1.5 × 2 cm, with no areas of ulceration (Fig. 94.1). No tenderness to touch with a probe. Speculum exam: Vaginal mucosa and cervix without gross lesions Bimanual exam: No cervical motion tenderness. The uterus was normal postmenopausal size and the adnexa were without masses or tenderness to palpation Lymphatics: No inguinal lymphadenopathy Extremities: Negative Neurologic: Nonfocal.