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Latest Research on
Vulvar Disorders
        
BJOG. 2008 Mar;115(4):509-14.
Life events in patients with vulvodynia.
Plante AF, Kamm MA.
Department of Gastroenterology, St Mark's Hospital, London, UK

OBJECTIVE: Vulval pain, in the absence of pathology, may have a psychological basis that relates to life events. This study aimed to determine the nature of such events. DESIGN: Structured questionnaire about patient's symptoms and early-life events. SETTING: Private practice physiotherapist specialising in pelvic floor disorders. POPULATION: Patients with vulvodynia as their primary symptom and control patients being treated for urinary tract disorder or post-childbirth routine physiotherapy who had no vulval pain on direct questioning. METHODS: Questionnaire applied to consecutive patients referred for treatment. Seventy-eight consecutive women presenting with vulvodynia (mean age 34 years, mean duration of symptoms 48 months) and 78 controls (mean age 39 years). MAIN OUTCOME MEASURES: Incidence of life events. RESULTS: A similar proportion of both groups were married. Being in a new relationship (P < 0.04), adverse current or previous relationships (39 versus 9%, P < or =
0.01), parental divorce (26 versus 9%, P < or = 0.001), history of termination of pregnancy, and adverse childbirth experiences (P < 0.04) were more common in patients than in controls. A history of sexual abuse was not more common in patients with vulvodynia compared with controls (13 versus 10%, P = not significant). Lack of libido was common in patients with vulvodynia (94 versus 29%, P < 0.0001). CONCLUSIONS: Adverse life experiences, including conflict, are common in women with vulvodynia. These factors may be important in mediating the genesis of pain through stress-related mechanisms. Sexual interest is diminished in these women. Sexual abuse is not a factor in most of these women. These findings have implications for treatment.

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Pain Physician. 2008 Mar;11(2):215-24.
Ultrasound-guided interventional procedures for patients with chronic pelvic pain - a description of techniques and review of literature.
Peng PW, Tumber PS.
Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Chronic pelvic pain can present in various pain syndromes. In particular, interventional procedure plays an important diagnostic and therapeutic role in 3 types of pelvic pain syndromes: pudendal neuralgia, piriformis syndrome, and "border nerve" syndrome (ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy). The objective of this review is to discuss the ultrasound-guided approach of the interventional procedures commonly used for these 3 specific chronic pelvic pain syndromes. Piriformis syndrome is an uncommon cause of buttock and leg pain. Some treatment options include the injection of the piriformis muscle with local anesthetic and steroids or the injection of botulinum toxin. Various techniques for piriformis muscle injection have been described. CT scan and EMG-guidance are not widely available to interventional physicians, while fluoroscopy exposes the performers to radiation risk. Ultrasound allows direct visualization and real-time injection of the piriformis muscle. Chronic neuropathic pain arising from the lesion or dysfunction of the ilioinguinal nerve, iliohypograstric nerve, and genitofemoral nerve can be diagnosed and treated by injection to the invloved nerves. However, the existing techniques are confusing and contradictory. Ultrasonography allows visualization of the nerves or the structures important in the identification of the nerves and provides the opportunities for real-time injections. Pudendal neuralgia commonly presents as chronic debilitating pain in the penis, scrotum, labia, perineum, or anorectal region. A pudendal nerve block is crucial for the diagnosis and treatment of pudendal neuralgia. The pudendal nerve is located between the sacrospinous and sacrotuberous ligaments at the level of ischial spine. Ultrasonography, but not the conventional fluoroscopy, allows visualization of the nerve and the surrounding landmark structures. Ultrasound-guided techniques offer many advantages over the conventio
nal techniques. The ultrasound machine is portable and is more readily available to the pain specialist. It prevents patients and healthcare professionals from the exposure to radiation during the procedure. Because it allows the visualization of a wide variety of tissues, it potentially improves the accuracy of the needle placement, as exemplified by various interventional procedures in the pelvic regions aforementioned.

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J Reprod Med. 2008 Feb;53(2):102-10.
Influence of oral contraceptive use on the risk of adult-onset vulvodynia.
Harlow BL, Vitonis AF, Stewart EG.
Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South 2nd Street, Suite 300, Minneapolis, MN 55454, USA. harlow@epi.umn.edu

OBJECTIVE: To examine the association of adult-onset vulvodynia with oral contraceptive use. STUDY DESIGN: We conducted a population-based study of 177 women experiencing vulvar pain consistent with clinical criteria for vulvodynia and community-matched controls. Analyses were repeated and validated in clinically confirmed clinic-based and population-based cases and matched controls. RESULTS: In our analyses of population-based cases and controls, oral contraceptive use was associated with a nonsignificant, 30% increase in the risk of vulvodynia (95% CI 0.7-2.3) and was highest among women whose first use occurred before age 18 (OR = 2.5, 95% CI 1.1-5.8). These findings were similar when restricted to clinically confirmed cases. CONCLUSION: These findings do not support the strong associations observed in clinic-based studies. In our study, clinically confirmed clinic-based cases, as compared to population-based cases, were more often oral contraceptive users, earlier-age users and users for longer periods. Thus, observational studies using clinic-based cases might not adequately represent oral contraceptive use in all women with vulvodynia.

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Clin J Pain. 2008 Feb;24(2):155-71.
The treatment of provoked vestibulodynia: a critical review.
Landry T, Bergeron S, Dupuis MJ, Desrochers G.
Department of Sexology, Université du Québec à Montréal, Montreal, Canada. landry.tina@courrier.uqam.ca

OBJECTIVE: To carry out a critical review of published studies concerning the treatment of provoked vestibulodynia. METHODS: MEDLINE, PsycINFO, and Cochrane were used to identify treatment studies published between January 1996 and December 2006. All studies published in English that dealt specifically with the treatment of provoked vestibulodynia were included in the review regardless of their methodological quality. Thirty-eight treatment studies were thus examined in the present paper. RESULTS: Since 1996, surgical treatment has received somewhat less empirical attention. Nevertheless, it still boasts the best success rates, which range from 61% to 94%. More studies have focused on medical treatments, yielding success rates varying between 13% and 67%. Behavioral treatments have been the least studied, although 35% to 83% of patients benefit from them. Despite these interesting results, only 5 of the 38 treatment studies reviewed are randomized clinical trials. Furthermore
, the majority of studies have several methodological weaknesses, such as the absence of (1) control or placebo group, (2) double-blind evaluation, (3) pretreatment pain evaluation, and (4) validated measures of pain and sexual functioning. DISCUSSION: On the basis of the results of the reviewed prospective studies and the randomized clinical trials, vestibulectomy is the most efficacious treatment to date. Though some medical treatments seem little effective, others appear promising and should be investigated further, as is the case with behavioral treatments. Additional randomized clinical trials are necessary to confirm the efficacy of surgery and validate nonsurgical treatments for provoked vestibulodynia.

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Dermatol Online J. 2008 Jan 15;14(1):2.
Vulvodynia.
Ventolini G, Barhan SM.
Wright State University, USA.

Vulvodynia or vulvar pain syndrome is a chronic, heterogeneous, and multifactorial disease with a high prevalence. This condition affects Caucasians, African Americans, Africans and Hispanic women, particularly those sexually active at child-bearing age. The etiology of this condition is complex and remains elusive. An accurate diagnosis requires a comprehensive history, physical examination and targeted diagnostic tests. Although many treatment options have been utilized, a rational therapeutic strategy is still under research. Psychological counseling and group support should be considered in all cases.

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Obstet Gynecol. 2008 Jan;111(1):159-66.
Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome.
Bergeron S, Khalifé S, Glazer HI, Binik YM.
Department of Sexology, Université du Québec à Montréal, Montréal, Québec, Canada. bergeron.sophie@uqam.ca

OBJECTIVE: To estimate whether treatment gains for provoked vestibulodynia participants randomly assigned to vestibulectomy, biofeedback, and cognitive-behavioral therapy in a previous study would be maintained from the last assessment-a 6-month follow-up-to the present 2.5-year follow-up. Although all three treatments yielded significant improvements at 6-month follow-up, vestibulectomy resulted in approximately twice the pain reduction as compared with the two other treatments. A second goal of the present study was to identify predictors of outcome. METHODS: In a university hospital, 51 of the 78 women from the original study were reassessed 2.5 years after the end of their treatment. They completed 1) a gynecologic examination involving the cotton-swab test, 2) a structured interview, and 3) validated pain and sexual functioning measures. RESULTS: Results from the multivariate analysis of variance conducted on the pain measures showed a significant time main effect (P<.05) and a significant treatment main effect (P<.01), indicating that participants had less pain at the 2.5-year follow-up than at the previous 6-month follow-up. Results from the multivariate analysis of variance conducted on sexual functioning measures showed that participants remained unchanged between the 6-month and 2.5-year follow-up and that there were no group differences. Higher pretreatment pain intensity predicted poorer outcomes at the 2.5-year follow-up for vestibulectomy (P<.01), biofeedback (P<.05), and cognitive-behavioral therapy (P<.01). Erotophobia also predicted a poorer outcome for vestibulectomy (P<.001). CONCLUSION: Treatment gains were maintained at the 2.5-year follow-up. Outcome was predicted by pretreatment pain and psychosexual factors. LEVEL OF EVIDENCE: II.

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Medscape J Med. 2008 Jan 30;10(1):23.
The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: an observational multicentric study.
Murina F, Bernorio R, Palmiotto R.
V. Buzzi Hospital, Milan, Italy Author's email: filippomurina@tin.it.

OBJECTIVE: To assess the effectiveness of a specific set of vaginal dilators (Amielle Comfort) as a part of vestibulodynia therapy. STUDY DESIGN: Fifteen women referred for vestibulodynia, localized vulvodynia, were advised to use vaginal dilators (Amielle Comfort) accompanied by standardized instructions, after previously receiving 1 or more therapies for the vestibulodynia. RESULTS: The post-treatment Marinoff scale for dyspareunia significantly improved in patients after vaginal dilator treatment compared with baseline values (2.2 +/- 0.4 vs 1.1 +/- 0.9; P < .01), and the Female Sexual Function Index scores were significantly improved compared with the prestudy values (16.3 +/- 5.5 vs 25.3 +/- 7.5; P < .01). CONCLUSION: Among women with previous therapy for vestibulodynia, vaginal dilator use was associated with improvement in symptoms. Vaginal dilators can play an important role in overcoming pelvic floor muscular responses that remain and sometimes increase after pain pe
rception has decreased.

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Am J Obstet Gynecol. 2008 Jan;198(1):41.e1-5. Epub 2007 Oct 22.
Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome.
Rapkin AJ, McDonald JS, Morgan M.
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA Los Angeles, CA, USA.

OBJECTIVE: Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed to evaluate a novel treatment approach. STUDY DESIGN: This is a prospective study of 27 women with vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block, and vestibular infiltration of local anesthetic agents. RESULTS: There were significant improvements in vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the Female Sexual Functioning Inventory. CONCLUSION: Serial multilevel nerve blocks administered for the treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective and merits a placebo-controlled study.

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Obstet Gynecol Surv. 2007 Dec;62(12):812-9.
Vulvodynia: new thoughts on a devastating condition.
Gunter J.
Pelvic Pain and Vulvovaginal Disorders, Kaiser Northern California, OB/GYN, San Francisco, California 94115, USA. jennifer.gunter@kp.org

Vulvodynia affects 3% to 15% of women; many suffer through years of misdiagnosis and for those who receive care cures are uncommon. Little is known about the etiology and a wide range of therapeutic options are available. With treatment approximately 50% of women will report sustained improvement in pain scores of 50% or more, however, reasons for varied response rates are yet unknown. This article will explore 3 factors that may contribute to inconsistent results with therapy; the hypothesis that vulvodynia is a systemic disorder; the idea that failure to address the psychological or emotional aspect or chronic pain may affect outcome; and the concept that chronic vulvar pain, like headache, is not a single condition but is a diverse group of disorders that produce the same symptom. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to state that vulvodynia is a complex disorder, explain that no one treatment is superior, relate that pathophysiology is important, and recall that psychological aspects of chronic pain must be appreciated.

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Gynecol Oncol. 2007 Dec 21 [Epub ahead of print]
Comparison of outcome measures in patients with advanced squamous cell carcinoma of the vulva treated with surgery or primary chemoradiation.
Landrum LM, Skaggs V, Gould N, Walker JL, McMeekin DS.
Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, University of Oklahoma Health Sciences Center, PO Box 26901, Williams Pavilion 2410, Oklahoma City, OK 73190, USA.

OBJECTIVE.: To review outcome measures including overall survival (OS), progression free survival (PFS), and patterns of recurrence in patients with advanced vulvar cancer managed by primary surgery (PS) or primary chemoradiation (PCRT) as well as population characteristics for the two groups. METHODS.: Patients diagnosed with stage III and IV squamous cell carcinoma of the vulva from 1990 to 2006 were identified for retrospective analysis at a single institution. Charts were abstracted for clinical and pathologic findings, treatment modalities, complications, recurrence, and follow-up. Kaplan-Meier method was used to determine PFS and OS. RESULTS.: Sixty-three patients with stage III (n=47) and IV (n=16) carcinoma of the vulva were identified; 30 patients were treated with PS, and 33 patients had tumor that was unresectable by vulvectomy and underwent PCRT. Patients treated with PCRT were younger (61 vs. 72 years; p=0.09), had less metastasis to lymph nodes (54% vs. 83%, p=0.01), and larger tumors (6 vs. 3.5 cm, p=0.0001) compared to patients treated with PS. Despite these differences, OS for the PS and PCRT groups was 69% and 76% (NS), respectively, with median follow-up at 31 months. There were no differences in PFS or recurrence rates between the two groups. By multivariate analysis, age was the only significant predictor of OS or PFS. CONCLUSIONS.: Patients with advanced vulvar cancer that are managed with PS tend to be older patients that have smaller lesions but positive lymph nodes, whereas patients requiring PCRT are younger and have larger volume disease but fewer lymph node metastases. Despite these differences, patients treated with PS and PCRT have no differences in OS, PFS, or recurrence rates. Age is the most powerful predictor of survival when size, lymph node status, stage and treatment are accounted for.

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Obstet Gynecol Clin North Am. 2007 Dec;34(4):783-802.
Vulvo-vaginal cancers: risks, evaluation, prevention and early detection.
Duong TH, Flowers LC.
Division of Gynecologic Specialties, Section of Urogynecology and Pelvic Reconstructive Surgery, 69 Jessie Hill Jr. Drive SE. Glenn Building 4th floor, Rm 402, Atlanta, GA 30303, USA.

Vulvar and vaginal cancers are rare and account for approximately 7% of cancers of the female reproductive tract. Vulvar and vaginal neoplasia share similar risk factors: human papillomavirus infection, previous cervical intraepithelial neoplasia or cervical cancer, current smoking, sexual factors, and immunosuppression. Several treatment options are available for patients with documented histologic high-grade intraepithelial vulvar or vaginal neoplasia, including excision, laser vaporization, and 5-fluorouracil. After treatment, lifetime follow-up with cytology and colposcopy is recommended. With the widespread use of the human papillomavirus vaccine, one half to two thirds of vulvar and vaginal cancers may be prevented. Patient education regarding reduction of risk factors for progression and close surveillance of at-risk individuals may prevent the progression to invasive disease.

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Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov 24 [Epub ahead of print]
Painful bladder syndrome/interstitial cystitis and vulvodynia: a clinical correlation.
Peters K, Girdler B, Carrico D, Ibrahim I, Diokno A.
Department of Urology, William Beaumont Hospital, Royal Oak, MI, USA, dcarrico@beaumonthospitals.com.

Vulvodynia affects 25% of women with painful bladder syndrome/interstitial cystitis (PBS/IC). The objective of our study was to clinically evaluate the association of PBS/IC and vulvodynia and possible contributing factors. To our knowledge, this has not been reported. Seventy women with PBS/IC were evaluated from December 2005 to December 2006 with a comprehensive history and exam. Two groups were formed-those with vulvodynia and those without vulvodynia for comparison. Of the women, 51.4% had vulvodynia and 48.6% did not have vulvodynia using our operative definition. Average levator pain levels were significantly greater in those with vulvodynia. There was no significant difference in the total number of lifetime pelvic surgeries, history of sexually transmitted infections (STIs), vaginitis, or abuse history between groups. The correlation of vulvodynia and PBS/IC may have been underestimated. Research needs to explore the link between precipitating factors, symptoms, and effective treatment options for PBS/IC and vulvodynia.

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J Reprod Med. 2007 Oct;52(10):912-6.
Improvement in vulvar vestibulitis with montelukast.
Kamdar N, Fisher L, MacNeill C.
Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.

OBJECTIVE: To determine if montelukast treatment improves symptoms in patients with vulvar vestibulitis. STUDY DESIGN: We administered montelukast to a series of patients with vestibulitis seen at the Pennsylvania State University Vulvodynia Clinic over a period of 2.5 years. We reviewed outcomes using a scoring scheme to quantify signs and symptoms, before and after treatment, in 29 montelukast-treated subjects and 18 subjects in a comparison group treated with standard therapies. RESULTS: Subjects treated with montelukast showed an average of 52% in improvement in symptoms as compared to a 15% improvement in the controls (p < 0.0001). CONCLUSION: Montelukast is a viable treatment option for women with vulvar vestibulitis. This finding implies that leukotrienes have a role in the pathophysiology of vulvar vestibulitis.

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Arch Sex Behav. 2007 Sep 18; [Epub ahead of print]
"If Sex Hurts, Am I Still a Woman?" The Subjective Experience of Vulvodynia in Hetero-Sexual Women.
Ayling K, Ussher JM.
Gender, Culture and Health Research Unit: PsyHealth, School of Psychology, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, 1797, Australia, j.ussher@uws.edu.au.

Vulvodynia has recently been recognized as a significant health problem among women, with a considerable proportion experiencing psychological distress and sexual dysfunction for many years. This study used a material-discursive framework and a qualitative methodology to investigate women's subjective experience of vulvodynia within the context of a hetero-sexual relationship, and their negotiation of coitus, commonly associated with vulvar pain. Seven women, who had experienced vulvodynia between 2 and 10 years, took part in in-depth interviews. Thematic decomposition drawing on a Foucauldian framework for interpretation identified that six of the seven women took up subject positions of "inadequate woman" and "inadequate partner," positioning themselves as failures for experiencing pain during coitus, which they interpreted as affecting their ability to satisfy their partners sexually, resulting in feelings of shame, guilt, and a decreased desire for sexual contact. This was interpreted in relation to dominant discourses of femininity and hetero-sexuality, which conflate a woman's sexuality with her need to be romantically attached to a man, position men as having a driven need for sex, and uphold coitus as the organizing feature of hetero-sex. Only one woman positioned herself as an "adequate woman/partner," associated with having renegotiated the coital imperative and the male sex drive discourse within her relationship. These positions, along with women's agentic attempts to resist them, were discussed in relation to their impact on hetero-sexual women's negotiation of vulvodynia. Implications for future research and vulvodynia treatment regimes are also raised.

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Clin Obstet Gynecol. 2007 Sep;50(3):745-51.
Unique dermatologic aspects of the postmenopausal vulva.
Summers PR, Hunn J.
Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA. paul.summers@hsc.utah.edu

Aging and estrogen deficiency compromise the skin barrier's defense mechanisms, resulting in greater microbial colonization of the skin. Susceptibility to mechanical injury and chemical irritation also increases. Menopause blunts the cell-mediated immune response to microbes and allergens. Healing after an insult is delayed. Skin disorders such as lichen sclerosus or allergic dermatitis may not be clinically obvious. A biopsy interpreted by a dermatopathologist is often helpful. Some conditions require long-term use of topical steroid ointments, and antimicrobial therapy. A compounding pharmacist may be necessary to find a base for the topical cream that does not irritate.

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J Reprod Med. 2007 Jul;52(7):645-53.
Novel bioadhesive patch-type system for photodynamic vulvodynia therapy after delivery of 5-aminolevulinic acid: preliminary evaluation.
Zawislak AA, McCarron PA, McCluggage WG, Donnelly RF, Price JH, McClelland HR, Woolfson AD.
Department of Gynaecology, Belfast City Hospital; School of Pharmacy, Queen's University Belfast, UK.

OBJECTIVE: To assess the applicability of photodynamic therapy (PDT) in the management of vulvodynia whereby a novel, patch-type system, loaded with 5-aminolevulinic acid (ALA), was used to administer PDT to vulvar regions displaying the characteristics of vulvodynia. STUDY DESIGN: Eleven patients underwent PDT using a bioadhesive patch to deliver ALA over 4 hours. A nonlaser light source delivered 100 J cm(-2) to the target area using red light of 630 nm. Fluorescence of protoporphyrin IX was observed under ultraviolet light illumination, with no significant difference found between that produced after the first and second applications of the patch. RESULTS: There was a significant reduction (p= 0.0077) in overall symptoms after completion of treatment. No significant alleviation (p = 0.1088) in pain during intercourse was observed following treatment. Eight patients experienced a symptomatic response, while 3 exhibited no improvements in symptoms. No adverse reactions or worsening of reported symptoms was reported. CONCLUSION: The results suggest that PDT is of value in the management of vulvodynia, most probably as a viable option to conventional approaches. Further studies involving larger numbers of patients are required to confirm the efficacy of PDT in the management of vulvodynia.

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Gynecol Obstet Invest. 2007 Jul 27;64(4):180-186 [Epub ahead of print]
Pimecrolimus Cream 1% for Treatment of Vulvar Lichen Simplex Chronicus: An Open-Label, Preliminary Trial.
Goldstein AT, Parneix-Spake A, McCormick CL, Burrows LJ.
Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Md., USA.

Background: To evaluate efficacy and safety of pimecrolimus cream 1% twice daily for treatment of vulvar lichen simplex chronicus (LSC). Methods: Patients in this 12-week, open-label study had biopsy-proven vulvar LSC. Inclusion criteria were patient-reported Visual Analog Scale for Pruritus Relief >/=3 (VAS-PR, 0 cm = no itching to 10 cm = severe itching) and Investigator's Global Assessment >/=2 (IGA, 0 = no disease to 3 = severe disease). Safety was evaluated by adverse event reports and pimecrolimus blood level measurements. Results: Twelve women aged 25-53 years were enrolled. The median pruritus score (VAS-PR) decreased from 6 (min. 4.9, max. 9.0) at baseline to 0 cm at week 4 (max. 4.2), week 8 (max. 3.1) and week 12 (max. 2.1). Seven patients reported complete resolution of pruritus by week 4. Median IGA decreased from 2.5 (min. 2, max. 3) at baseline to 0 (min. 0, max. 2) at week 12. Erythema, excoriation, and lichenification improved for all patients. Pimecrolimus blood concentration for all samples was below the limit of quantification, 0.3 ng/ml. No adverse events were reported. Conclusions: In this exploratory study, signs and symptoms of vulvar LSC improved for all women and pimecrolimus cream showed a favorable safety profile. Larger prospective studies are needed to further evaluate pimecrolimus for treatment of vulvar LSC. Copyright (c) 2007 S. Karger AG, Basel.

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Menopause. 2007 Jun 28; [Epub ahead of print]
Vulvar lichen sclerosus: effect of maintenance treatment with a moisturizer on the course of the disease.
Simonart T, Lahaye M, Simonart JM.
From the 1Department of Dermatology, Erasme University Hospital; 2Department of Gynaecology, Centre Medical des Champs Elysees; and 3private dermatological practice, Brussels, Belgium.

OBJECTIVES:: Vulvar lichen sclerosus (LS) is an inflammatory disease of unknown etiology that may result in significant discomfort and psychological distress in postmenopausal women. One of the most troublesome features of LS is its chronically relapsing nature. The aim of this study was to investigate the effect of maintenance therapy with a moisturizer in preventing the risk of relapse and progression of vulvar LS in postmenopausal women. DESIGN:: Between January 1995 and January 2006, 34 postmenopausal women with vulvar LS were included in a prospective open trial. The participants were treated with a topical corticosteroid cream (0.1% betamethasone valerate) once daily for 1 month and then with maintenance therapy with a moisturizing cream alone once daily. Follow-up visits were scheduled after 1 month and then twice per year (median follow-up, 58 mo). RESULTS:: Overall the symptoms of all women improved after therapy with a topical steroid. Twenty-four women (71%) became symptom free, and 10 (29%) experienced partial response. Eighteen of the 24 women (75%) who became symptom free and 6 of the 10 women (60%) who exhibited a partial response reported no worsening of their symptoms while on therapy with a cold cream alone. Total resolution of the clinical signs occurred in 6 of the 19 women with mild vulvar architectural changes. Partial resolution of clinical signs was observed in 22 women (64%). No change was noticed in six (18%) women. None of the participants experienced worsening of vulvar scarring. None of the participants developed vulvar intraepithelial neoplasia or squamous cell carcinoma during the follow-up period. There were no side effects. CONCLUSION:: Long-term maintenance therapy of vulvar LS with a moisturizing cream can maintain the symptom relief induced by topical corticosteroids in women with vulvar LS while being safe and inexpensive. This treatment may also be associated with a reduction in topical corticosteroid use because more than half of the women could eliminate corticosteroids altogether.

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J Reprod Med. 2007 May;52(5):379-84.
Is localized, provoked vulvodynia an inflammatory condition?
Eva LJ, Rolfe KJ, MacLean AB, Reid WM, Fong AC, Crow J, Perrett CW.
Department of Obstetrics and Gynecology, Royal Free and University College Medical School, Royal Free Campus, London, UK.

OBJECTIVE: To perform a pilot study to investigate the relationship between localized, provoked vulvodynia of the vestibule and inflammatory cytokine expression. STUDY DESIGN: Women with a diagnosis of localized, provoked vulvodynia had tissue samples taken for vulvar expression of Interleukin 1alpha and 1beta and tumor necrosis factor alpha and compared to those of a control group. RESULTS: The study group did not show a significant increase in expression of inflammatory markers. CONCLUSION: There was no evidence in this study that localized, provoked vulvodynia is an inflammatory condition, as previously thought. This may be helpful in explaining why some women are resistant to medical or antiinflammatory treatment and may allow treatment to be prescribed more effectively.

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ScientificWorldJournal. 2006 Mar 7;6:2066-79.
Clinical holistic medicine: holistic sexology and acupressure through the vagina (hippocratic pelvic massage).
Ventegodt S, Clausen B, Omar HA, Merrick J.

Many gynecological and sexological problems (like urine incontinence, chronic pelvic pains, vulvodynia, and lack of lust, excitement, and orgasm) are resistant to standard medical treatment. In our work at the Research Clinic for Holistic Medicine in Copenhagen, we have found that vaginal acupressure, or Hippocratic pelvic massage, can help some of these problems. Technically, it is a very simple procedure as it corresponds to the explorative phase of the standard pelvic examination, supplemented with the patient's report on the feelings it provokes and the processing and integration of these feelings. Sometimes it can be very difficult to control the emotions released by the technique, i.e., regression to earlier traumas from childhood sexual abuse. This review discusses the theory behind vaginal acupressure, ethical aspects, and presentation of a case story. This procedure helped the patient to become present in her pelvis and to integrate old traumas with painful emotions. Holistic gynecology and sexology can help the patient to identify and let go of negative feelings, beliefs, and attitudes related to sex, gender, sexual organs, body, and soul at large. Shame, guilt, helplessness, fear, disgust, anxiety, anger, hatred, and other strong feelings are almost always an important part of a sexual or functional problem as these feelings are "held" by the tissue of the pelvis and sexual organs. Acupressure through the vagina/pelvic massage must be done with great care by an experienced physician, with a third person present, after obtaining consent and the necessary trust of the patient. It must be followed by conversational therapy and further holistic existential processing.

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J Reprod Med. 2007 Feb;52(2):107-10.
Vulvodynia as a possible somatization disorder. More than just an opinion.
Mascherpa F, Bogliatto F, Lynch PJ, Micheletti L, Benedetto C.
Department of Gynecology and Obstetrics, University of Torino, Torino, Italy. franco.mascherpa@virgilio.it

Vulvodynia, defined as vulvar pain, soreness or burning as opposed to pruritus, is a common and important problem. Despite its high prevalence and associated distress, the etiology, diagnosis and management of this disorder have not been clearly delineated. On the basis of recent advances in psychosomatic medicine, vulvodynia can be considered a somatiform disorder affecting the vulva. Psychosomatic assessment is useful in patients with vulvodynia. This review covered recent advances in psychosomatic medicine with reference to somatization disorders and their application to vulvodynia. According to the literature, vulvodynia shares some basic criteria by which functional pain disturbances are defined. Thus, all patients with vulvodynia should undergo psychologic and sexual evaluation since in some instances psychotherapy may offer the only successful approach to the alleviation of vulvar pain.

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J Reprod Med. 2007 Feb;52(2):103-6.
Evaluation of gabapentin in the treatment of generalized vulvodynia, unprovoked.
Harris G, Horowitz B, Borgida A.
Department of Obstetrics and Gynecology, University of Connecticut, Farmington, USA. chazzanmlp@aol.com

OBJECTIVE: To determine the efficacy of gabapentin in the treatment of generalized vulvodynia, unprovoked, to determine the most common presenting symptoms in patients with this diagnosis, to evaluate the prevalence of comorbidities in these patients and to determine the possibility of comorbidities or specific presenting symptoms that decrease the efficacy of this drug. STUDY DESIGN: The charts of all women seen in our facility with a diagnosis of generalized vulvodynia between January 1, 2002, and September 30, 2004, were reviewed. A total of 601 charts were reviewed. Patients were included in the study if they had a diagnosis of generalized vulvodynia, they were treated with single-agent gabapentin, had follow-up for 30 months or more and had adequately documented follow-up. RESULTS: A total of 152 patients were included in the study. Ninety-eight (64%) patients treated with gabapentin had resolution of at least 80% of their symptoms during the study period. Forty-nine (32%) did not have adequate resolution. There was a high percentage of comorbidities in patients with generalized vulvodynia. Sleep disturbance was the only comorbidity that negatively affected the efficacy of gabapentin. In addition, there appeared to be a trend toward a less favorable response in patients with a longer period of untreated illness (p value not less than 0.05). Side effects of gabapentin were few. Forty (26%) reported some side effects. Fatigue was the most common complaint. Seventeen patients (11%) discontinued the medication secondary to side effects. CONCLUSION: Gabapentin appears to be very effective in the treatment of generalized vulvodynia, unprovoked. It has a very low side effect profile. Certain patients may be less likely to benefit from gabapentin, including those with the comorbidity of sleep disturbance. Patients with symptoms of longer-standing generalized vulvodynia, unprovoked, may also be less likely to benefit from this treatment.

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Am J Obstet Gynecol. 2007 Feb;196(2):128.e1-6.
Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study.
Arnold LD, Bachmann GA, Rosen R, Rhoads GG.
Department of Epidemiology, School of Public Health, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

OBJECTIVE: Vulvodynia is a chronic pain syndrome of unknown origin with scant data on frequency. This study assessed the prevalence of vulvodynia symptoms in a sample of US women and compared health characteristics of symptomatic and asymptomatic women. STUDY DESIGN: A phone survey contacted 2127 US households to identify 100 symptomatic women, who were matched on age and time zone to 325 asymptomatic controls. Odds ratios (ORs) and logistic regression were used to model associations between pain, medical conditions, and health care utilization variables. RESULTS: Current vulvar pain of at least 6 months duration was reported by 3.8% of respondents, with a 9.9% lifetime prevalence. Forty-five percent of women with pain reported an adverse effect on their sexual life and 27% an adverse effect on their lifestyle. Cases more frequently reported repeated urinary tract infections (OR, 6.15; 95% CI, 3.51-10.77) and yeast infections (OR, 4.24; 95% CI, 2.47-7.28). Associations existed with chronic fatigue syndrome (OR, 2.78; 95% CI, 1.33-6.19), fibromyalgia (OR, 2.15; 95% CI, 1.06-4.36), depression (OR, 2.99; 95% CI, 1.87-4.80), and irritable bowel syndrome (OR, 1.86; 95% CI, 1.07-3.23). CONCLUSION: Lifetime chronic vulvar pain was less prevalent in this national sample of women than previous data suggest and was correlated with several comorbid chronic medical conditions and substantial reduction in self-reported quality of life.

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J Reprod Med. 2007 Jan;52(1):63-71.
Vulvodynia. Development of a psychosexual profile.
Jantos M, Burns NR.
School of Psychology, University of Adelaide, Adelaide, South Australia. marek.jantos@adelaide.edu.au

OBJECTIVE: To assess the psychosexual profile of vulvodynia patients, focusing on the age at onset and age distribution, and to analyze the impact of vulvodynia on the emotional, social and sexual well-being of this patient population. STUDY DESIGN: A retrospective review was performed of patient files consisting of questionnaires, psychometric tests, sexual history, electromyographic assessments and clinical notes. RESULTS: The highest prevalence of vulvodynia in this clinical sample occurred before the age of 25 years; 75% of the 744 patients were under the age of 34. A comparison of primary and secondary vulvodynia patients showed the average age at symptom onset to be 19.1 years for primary cases and 25.0 years for secondary cases. There were significant differences in duration of symptoms, age at first sexual intercourse and number of sexual partners, even when controlling for age (p < 0.001). Marriage provided an effective buffer against depression and anxiety. CONCLUSION: Vulvodynia can have an early onset and affect social relationships. Given the psychologic distress associated with vulvodynia, early diagnosis and treatment of the medical aspects are essential, as is focusing on the psychosexual implications of this pain syndrome.

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J Reprod Med. 2007 Jan;52(1):19-22.
A qualitative study of women with vulvodynia: II. Response to a multidisciplinary approach to management.
Munday P, Buchan A, Ravenhill G, Wiggs A, Brooks F.
Watford Sexual Health Centre and Department of Physiotherapy, West Hertfordshire Hospitals National Health Service Trust, and Centre for Research in Primary and Community Care, University of Hertfordshire, Watford, UK. pat.munday@whht.nhs.uk

OBJECTIVE: To evaluate the response of a group of women with vulvodynia who were participating in an integrated, multidisciplinary management program comprising medical evaluation and treatment, psychotherapy, physiotherapy and dietary advice. STUDY DESIGN: Retrospective, qualitative, in-depth interview study. RESULTS: Twenty-seven of 29 women reported a significant benefit, and 9 who had completed the program were pain free. All women appreciated the integrated approach, and even those who were not completely pain free found that they were able to manage their condition satisfactorily. CONCLUSION: Further evaluation of this program is warranted to assess whether it would be helpfulfor other women with this problem.

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Clin Infect Dis. 2007 Jan 15;44(2):213-9. Epub 2006 Dec 13.
A randomized trial of the duration of therapy with metronidazole plus or minus azithromycin for treatment of symptomatic bacterial vaginosis.
Schwebke JR, Desmond RA.
Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA. schwebke@uab.edu

BACKGROUND: Bacterial vaginosis (BV) is the most common cause of vaginitis worldwide. Currently recommended treatments have poor efficacy and are associated with high rates of BV recurrence. We examined whether a longer duration of treatment with metronidazole or combination therapy with metronidazole and azithromycin would enhance the cure rates for BV. In addition, we examined factors other than drug therapy associated with cure. METHODS: Women with symptomatic BV (defined by a modified Amsel criteria) were enrolled in a 4-arm study that compared metronidazole for 7 days versus 14 days, plus or minus azithromycin on days 1 and 3. Data regarding interim behaviors were also obtained, as were vaginal specimens for Gram staining. RESULTS: At the first follow-up visit (7 days after the completion of therapy), there was a significant difference in cure rates among patients who received 7 days of metronidazole therapy, compared with those who received 14 days of therapy, combined across azithromycin therapy (P=.0003). There was no effect associated with azithromycin therapy. There were no differences in cure rates between any of the treatment groups at 21 days after completion of therapy. Abstinence or protected sex, refraining from douching, and a lower baseline Nugent score for the vaginal Gram stain were all significantly associated with cure. CONCLUSIONS: Cure rates for BV were significantly improved by 14 days of metronidazole treatment (compared with 7 days of treatment), but the effects were not sustained, suggesting that relapse or reinfection occurred. Combination therapy with the addition of azithromycin had no benefit. Lower baseline Nugent scores--presumably reflecting less complex vaginal flora--were significantly associated with cure, as was refraining from unprotected sex and from douching.

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J Low Genit Tract Dis. 2006 Oct;10(4):245-51.
Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors.
Reed BD, Caron AM, Gorenflo DW, Haefner HK.
Department of Family Medicine, University of Michigan, Ann Arbor, MI 48109-0708, USA. barbr@umich.edu

OBJECTIVE: To determine the efficacy of tricyclic antidepressants (TCAs) as treatment for vulvodynia, and to identify demographic factors and pain characteristics associated with improvement. MATERIALS AND METHODS: Between January 2001 and April 2004, women diagnosed with vulvodynia were offered TCA therapy. The patients rated their worst recent pain on a 10-point scale at baseline and at follow-up; improvement was classified as at least 50% reduction in reported pain from baseline. RESULTS: Of 271 women diagnosed with vulvodynia, 209 (77.1%) were treated initially with a TCA (amitriptyline [n = 183], desipramine [n = 23], and other tricyclic medications [n = 3]). One hundred sixty-two (59.8%) of the women were followed up at a median period of 3.2 months after their initial visit, including 122 women who had started on a TCA. Of 83 women taking a TCA at the first follow-up, 49 (59.3%) improved by more than 50%, compared with 30 of 79 women not taking TCA at follow-up (improvement rate = 38.0%; p =.007; odds ratio = 2.35; 95% CI = 1.23-4.42). Multivariate analysis indicated that age, severity of pain, diagnosis (localized vs generalized vulvar pain), length of time with pain before treatment, age at menarche, use of oral contraceptives, and the number of previous pregnancies were not associated with the outcome; however, taking a TCA at the time of the first follow-up was strongly associated with improvement (p <.001; odds ratio = 4.23; 95% CI = 1.98-9.01). Repeated analysis including only those women prescribed with amitriptyline rather than any tricyclic revealed similar results. CONCLUSIONS: Women with vulvodynia who were prescribed a TCA in general (or amitriptyline, specifically) were more likely to have pain improvement compared with those women not taking these medications at follow-up. Randomized, controlled studies of TCAs versus other treatments are needed to clarify the overall effectiveness of these drugs.

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J Chemother. 2006 Aug;18(4):409-14.
Topical kanamycin: an effective therapeutic option in aerobic vaginitis.
Tempera G, Abbadessa G, Bonfiglio G, Cammarata E, Cianci A, Corsello S, Raimondi A, Ettore G, Nicolosi D, Furneri PM.
Department of Microbiological and Gynecological Sciences, University of Catania, Via Androne 81, 95124 Catania, Italy. tempera@unict.it

Eighty-one patients with clinical diagnosis of aerobic vaginitis (AV) were included in the study. The patients were randomized for treatment, 45 with kanamycin (100 mg vaginal ovules for 6 days, consecutively) and 36 with meclocycline (35 mg vaginal ovules for 6 days, consecutively). The patients were examined before starting the study, 1-2 days after treatment and 30 days after the end of the study. At the first follow-up the patients showed different levels of symptom reduction. Reduction in the presence of leukocytes, vaginal mucosa burning and itching were statistically significant in the group treated with kanamycin with respect to the group treated with meclocycline. Moreover, there was also reduced isolation of Enterobacteriaeae (97%) in the group treated with kanamycin versus those treated with meclocycline (76%). At the second follow-up, vaginal homeostasis (normalization of pH and presence of lactobacilli) was more evident in the kanamycin-treated group. In conclusion, our data suggest that the topical use of kanamycin could be considered a specific antibiotic for the therapy of this new pathology.
 

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