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Is Vulval Vestibulitis Syndrome a Hormonal Condition?

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Is Vulval Vestibulitis Syndrome a Hormonal Condition? VULVAL VESTIBULITIS SYNDROME A Thesis submitted for the Degree of Doctor of Medicine University of London Lois Eva 1 UMI Number: U591707 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U591707 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 ABSTRACT Objective This project investigates ways of assessing Vulval Vestibulitis Syndrome (VVS), possible aetiological factors, and response to a range of treatments. Materials and Methods 1. Data were collected and analysed to identify possible epidemiological characteristics and compared to existing evidence. 2. Technology (an algesiometer) was used to reliably assess patients, and quantify response to treatment. 3. Immunohistochemistry was used to determine whether VVS is an inflammatory condition. 4. Immunohistochemistry was also used to investigate the expression of oestrogen and progesterone receptors in the vulval tissue of women with VVS and biochemical techniques were used to investigate any relationship with serum oestradiol. Results The cohort of women fulfilling the criteria for VVS were aged 22 to 53 (mean age 34.6) and for some there appeared to be an association with use of the combined oral contraceptive pill (cOCP). The algesiometer allowed quantification of pain, and improvement with treatment. There appears to be an overall decreased expression of inflammatory markers in women with VVS. There appears to be no correlation between serum oestradiol and VVS, however vulval tissue from women with VVS appears to express less oestrogen receptors, although there is no difference in the expression of progesterone receptors. Discussion VVS is a condition which appears to have well defined epidemiological characteristics, although subgroups may exist. There is evidence that it is not an inflammatory condition, as previously thought, giving weight to the current argument that it is not an “itis” and the condition should be defined as localised provoked vulvodynia, as proposed by the International Society for the Study of Vulvovaginal Disease (ISSVD) at their congress in 2003. The nomenclature and classification of vulval pain forever appears to be evolving. Since late 2003 the term Vulval Vestibulitis Syndrome is no longer recommended by the ISSVD, although it was the term in use at the time this work was performed. The patients were selected for the studies by fulfilling Friedrich’s criteria for W S, and therefore this term is used throughout this thesis CONTENTS ABSTRACT..............................................................................................................................2 List of figures .......................................................................................................................... 7 List of tables ........................................................................................................................... 8 ACKNOWLEDGEMENTS......................................................................................................9 PUBLICATIONS AND PRESENTATIONS ARISING FROM THIS THESIS................10 CHAPTER ONE - INTRODUCTION................................................................................... 12 Embryology of the vulva ...................................................................................................12 Anatomy of the vulva ........................................................................................................ 13 Histology of the vulva ........................................................................................................ 17 Ultrastructure of the vulval vestibule ...............................................................................19 Diseases of the vulva......................................................................................................... 21 Classification of Vulval Pain .............................................................................................21 Vulval Vestibulitis Syndrome.......................................................................................... 27 H istory .................................................................................................................................27 Diagnosis of vulval vestibulitis syndrome ...................................................................... 32 Pathology of vulval vestibulitis syndrome ..................................................................... 36 Epidemiology of vulval vestibulitis syndrome ................................................................40 Aetiology of vulval vestibulitis syndrome ....................................................................... 42 Infective causes ............................................................................................................ 44 Hormonal factors ........................................................................................................... 48 Psychological factors ................................................................................................... 51 Other aetiological factors .............................................................................................54 Molecular factors ........................................................................................................... 56 Treatment of vulval vestibulitis syndrome ..................................................................... 61 Medical Treatment ........................................................................................................61 Surgical Treatment ........................................................................................................66 Objectives of th esis ........................................................................................................... 71 CHAPTER TWO - ASSESSMENT OF VULVAL VESTIBULITIS SYNDROME 72 Examination of the vulva .................................................................................................. 73 Assessment of vestibular tenderness ............................................................................75 Algesiometry ..................................................................................................................77 S tudy ...................................................................................................................................79 M ethod ............................................................................................................................ 80 Results ............................................................................................................................ 82 Statistics..........................................................................................................................85 Discussion ...................................................................................................................... 86 Conclusion ..................................................................................................................... 88 CHAPTER THREE - EPIDEMIOLOGICAL CHARACTERISTICS OF STUDY PATIENTS WITH VULVAL VESTIBULITIS SYNDROME............................................. 89 Method ................................................................................................................................ 00 Results ................................................................................................................................ 02 Demographic details .................................................................................................... 02 Symptoms ...................................................................................................................... 02 Hormonal Factors ..........................................................................................................05 4 Menstrual history ....................................................................................................... 95 Contraception ............................................................................................................. 95 Obstetric history ..........................................................................................................97 Sexual Factors ............................................................................................................... 99 C oitus .......................................................................................................................... 99 Infections ...................................................................................................................100 Previous history ............................................................................................................ 100 Gynaecological .........................................................................................................100 M edical...................................................................................................................... 100 Family .......................................................................................................................
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