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A 67-year-old woman comes to the office with severe vulvar itching and burning for the past 6 months. The patient has tried over-the-counter, topical lubricants for her symptoms without relief. She is no longer sexually active because vaginal penetration is not possible due to pain. Medical history includes type 1 diabetes mellitus that is well controlled with insulin. The patient had a total vaginal hysterectomy at age 48 for adenomyosis. She previously had no abnormal Pap tests and has not had cervical cancer screening since the hysterectomy Vital signs are normal. Physical examination shows thin, dry, white, plaque-like vulvar skin with loss of the labia minora. There is clitoral hood retraction. Excoriations are present bilaterally on the vulva.