A 50-year-old postmenopausal woman, gravid 2, para 2, is referred for evaluation after her primary physician noted a vulvar lesion during a recent well woman examination. The patient reports a remote history of abnormal Pap smear for which she underwent an excisional procedure 15 years ago with normal follow-up cytology. Her last menstrual cycle was three years ago and she is not on hormone replacement. She is regularly sexually active with one male partner. She has smoked cigarettes for the past 30 years. An in-office biopsy of the lesion was performed.