DOCSLIB.ORG

Vulvar Leukoplakia: Therapeutic Options

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Vulvar Leukoplakia: Therapeutic Options DOI: https://doi.org/10.5114/pm.2020.99570 Menopause Rev 2020; 19(3): 135-139 Review papeR Vulvar leukoplakia: therapeutic options Angel Yordanov1, Latchezar Tantchev2, Stoyan Kostov3, Stanislav Slavchev3, Strahil Strashilov4, Polina Vasileva5 1Department of Gynaecological Oncology, Medical University of Pleven, Bulgaria 2Obstetrics and Gynaecology Clinic, Acibadem City Clinic Hospital “Tokuda”, Sofia, Bulgaria 3Department of Gynecology, Medical University of Varna, Bulgaria 4Department of Plastic Restorative, Reconstructive and Aesthetic Surgery, Medical University of Pleven, Bulgaria 5Department of Obstetrics and Gynaecology, Medical University of Pleven, Pleven, Bulgaria Abstract Vulvar leukoplakia is not a histological diagnosis and involves several diseases. Most commonly, these are vulvar lichen sclerosus and squamous cell hyperplasia of the vulva. These two conditions have similar aetiol- ogy, clinical presentation and treatment but different histopathological changes. They both lead to significant impairment of quality of life, risk of malignancy, as well as recurrence after treatment. Treatment of these conditions includes topical corticosteroids as a first-line therapy, but they have their side effects and not all patients are receptive to this therapy. This requires the use of alternative therapeutic options such as topical calcineurin inhibitors, topical and systemic retinoids, other steroid creams, various destructive techniques and, as a last resort, surgical removal of affected tissues. Surgical treatment should be avoided, despite the malignant potential, because of recurrence risk in both diseases New therapeutic approaches are coming into effect in gynaecological practice due to potential risks of the above-mentioned methods. Platelet-rich plasma therapy, ablative and non-ablative laser treatment, and new topical medicines, are some of the new options applied to improve the efficacy of treatment avoiding the side effects of conventional medications. A number of them are still in their initial phase of application and time will tell their effectiveness. Key words: vulvar leukoplakia, vulvar lichen sclerosus, squamous cell hyperplasia of the vulva, treatment. Introduction rich plasma (PRP) therapy, various destructive tech- The term vulvar leukoplakia is not a histological but niques, e.g. ablative and non-ablative laser treatments, a descriptive diagnosis meaning “white spot”. It is used alcohol-mediated denervation and, in the last instance, for non-inflammatory diseases characterized by patho- surgical removal of the affected tissues. logical modification of external genitalia multilayered flat epithelium that is accompanied by skin and mucosa cornification [1]. It combines various atrophic and hy- Aetiology pertrophic diseases of the vulva classified in the past as The two major diseases leading to white skin color- vulvar dystrophies [2]. This group includes lichen sclero- ation in the external genitalia are VLS and SCHV. These sus (LS), squamous cell hyperplasia, condyloma acumi- are chronic conditions and their occurrence is deter- nata, psoriasis, lichen planus, mixed LS and atrophicus. mined by many factors such as immunity, sexual hor- White colouration is caused by excessive keratin, at mones, injuries, environment, enzymes, free radicals, times deep pigmentation, and relative avascularity [3]. and apoptosis. It is assumed that VLS and SCHV are Two non-neoplastic epithelial disorders of the vulva – genetic immune diseases [5]. vulvar LS (VLS) and squamous cell hyperplasia of the VLS is the most common chronic lesion of the vulva vulva (SCHV) – are generally referred to as vulvar leuko- and mainly affects the anogenital area [4, 5], but may plakia. They have different anatomical and pathological have extragenital location as well. In 20% of patients features, but similar clinical manifestations. The fre- with anogenital involvement extragenital involvement is quency is 1 in 300 to 1,000 [4]. Treatment involves dif- found too [6-9]; in 6-15% of LS cases disease manifesta- ferent approaches such as topical medications, platelet- tions have extragenital locations only [8, 9]. The classical Corresponding author: Angel Yordanov, PhD, Department of Gynaecological Oncology, Medical University of Pleven, Submitted: 2.03.2020 1 Sv. Kliment Ohridski St., 5800 Pleven, Bulgaria, e-mail: [email protected] Accepted: 10.05.2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/) 135 Menopause Review/Przegląd Menopauzalny 19(3) 2020 histological findings of LS are a thinned epidermis and/ ing and redness of the skin and the lesion can further or the loss of rete ridges, hyperkeratosis, oedema and/or progress to white, thin, dry, and chapped skin and mu- hyalinization, as well as chronic band-like inflammatory cosa with a loss of elasticity as the disease advances. cell infiltrate of the dermis [10]. However, there are many There can be atrophy or even a reduction in the labio- variations to these classical histological characteristics rum minus [5]. leading to a myriad of lesions that may be classified as VLS and SCHV may cause significant vulvar chang- LS [11]. Macroscopically, the vulva is shiny and dry, with es affecting quality of life. Anatomical changes that are no creases. Lesions are often symmetrical. The disease caused by both conditions, especially from VLS, may is more common in postmenopausal women, but there lead to sexual dysfunction [13]. Both conditions have is a peak in its development in pre-pubertal girls as well an opportunity to relapse after treatment, and this is [7, 9, 12]. It affects mostly women aged 50-59 [4]. It is as- related to the method of treatment and patients’ age sumed to be of autoimmune genesis with a genetic pre- [20, 21]. disposition [5, 13]. Autoimmune diseases are diagnosed They have a malignant potential: 3 to 6% for VLS in 21% of cases of VLS, and in 22% of cases family history and 2 to 4% for SCHV [5]. It has been established that of the disease [2] affects sisters, mothers and daughters, VLS patients can develop vulvar squamous cell carci- and twin sisters including both homozygotic and hetero- noma for several years – from 3.3 to 8.8 years [22, 23]. zygotic twins [5]. About 80% of the cases of invasive squamous cell carci- The aetiology of SCHV is not well known. It is sup- noma (SCC) of the vulva in elderly patients are associat- posed there is a role of chronic irritation of the skin. Ir- ed with untreated, long-term VLS conditions [4]. ritants might include perfumed soaps, fabric condition- Because of the malignant potential of these diseas- ers and detergents used in the laundry of underwear es, many clinicians advocate that active management or even excessive washing [14]. It is thought that SCHV of VLS and SCHV can reduce the risk of malignant trans- is an autoimmune condition and it has been associat- formation [22]. ed with other autoimmune diseases such as malignant anaemia, thyroid diseases, diabetes mellitus, systemic lupus erythematosus, primary biliary cirrhosis, and bul- Diagnosis lous pemphigoid [2]. There is thinning of the affected skin in VLS, while The diagnosis of both diseases is clinical, which is the opposite is observed in SCHV – an abnormal growth sufficient in routine clinical practice. It is very easy to of the skin of the vulva. The histological features are diagnosticate then when the clinical presentation is typ- as follows: widening of the rete ridges and irregular ical, especially for LVS [24-26]. In some cases such as thickening of the Malpighian layer of rete ridges (acan- atypical features, uncertainty of diagnosis, concern for thosis); hyperkeratosis and chronic inflammation in the malignancy, or in failed response to treatment, biopsy is dermis; possibly increased mitotic figures in basal and mandatory. The gold standard to differentiate these con- prickle cell layers but no atypia; possible parakeratosis. ditions is histological – biopsy [22, 27]. Because biopsy This condition is characterized by a pink-red vulva is the only way to exclude SCC of the vulva and vulvar with overlying grey-white keratin and involved labium intraepithelial neoplasia, it is necessary in our opinion. majus, nympholabial furrow, preputium clitoridis, and commissura labiorum posterior. In the early stage of the disease, the skin might appear dark red or pink, while Treatment hyperkeratotic skin might appear white. Both diseases have similar treatment, but different The disease is predominant in postmenopausal wom- therapeutic options are available as well. The main goal en but can be observed in any lifetime period [15-17]. The of therapy is to control genital itching, which is a major average age of its occurrence is between 42 and 53 years problem for the patient. Management of pruritus vul- of age according to research literature [18, 19]. vae can be divided into four stages: (1) identification of underlying disease; (2) restoration of the skin barri- er function; (3) reduction of any inflammatory compli- Clinical manifestation cation; and (4) elimination of the itch-scratch cycle by The clinical picture in both conditions is similar, and psychological methods [28]. Asymptomatic VLS cases its main manifestation is itching in the vulva which is should be treated too. more expressed in SCHV than in VLS [5]. Other less The first course of action in both conditions is to common symptoms
Load more

Recommended publications
  • Vaginitis and Abnormal Vaginal Bleeding
    UCSF Family Medicine Board Review 2013 Vaginitis and Abnormal • There are no relevant financial relationships with any commercial Vaginal Bleeding interests to disclose Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine [email protected] Vulvovaginal Symptoms: CDC 2010: Trichomoniasis Differential Diagnosis Screening and Testing Category Condition • Screening indications – Infections Vaginal trichomoniasis (VT) HIV positive women: annually – Bacterial vaginosis (BV) Consider if “at risk”: new/multiple sex partners, history of STI, inconsistent condom use, sex work, IDU Vulvovaginal candidiasis (VVC) • Newer assays Skin Conditions Fungal vulvitis (candida, tinea) – Rapid antigen test: sensitivity, specificity vs. wet mount Contact dermatitis (irritant, allergic) – Aptima TMA T. vaginalis Analyte Specific Reagent (ASR) Vulvar dermatoses (LS, LP, LSC) • Other testing situations – Vulvar intraepithelial neoplasia (VIN) Suspect trich but NaCl slide neg culture or newer assays – Psychogenic Physiologic, psychogenic Pap with trich confirm if low risk • Consider retesting 3 months after treatment Trichomoniasis: Laboratory Tests CDC 2010: Vaginal Trichomoniasis Treatment Test Sensitivity Specificity Cost Comment Aptima TMA +4 (98%) +3 (98%) $$$ NAAT (like GC/Ct) • Recommended regimen Culture +3 (83%) +4 (100%) $$$ Not in most labs – Metronidazole 2 grams PO single dose Point of care – Tinidazole 2 grams PO single dose •Affirm VP III +3 +4 $$$ DNA probe • Alternative regimen (preferred for HIV infected
    [Show full text]
  • Localised Provoked Vestibulodynia (Vulvodynia): Assessment and Management
    FOCUS Localised provoked vestibulodynia (vulvodynia): assessment and management Helen Henzell, Karen Berzins Background hronic vulvar pain (pain lasting more than 3–6 months, but often years) is common. It is estimated to affect 4–8% of Vulvodynia is a chronic vulvar pain condition. Localised C women at any one time and 10–20% in their lifetime.1–3 provoked vestibulodynia (LPV) is the most common subset Little attention has been paid to the teaching of this condition of vulvodynia, the hallmark symptom being pain on vaginal so medical practitioners may not recognise the symptoms, and penetration. Young women are predominantly affected. LPV diagnosis is often delayed.2 Community awareness is low, but is a hidden condition that often results in distress and shame, increasing with media attention. Women can be confused by the is frequently unrecognised, and women usually see a number symptoms and not know how to discuss vulvar pain. The onus is of health professionals before being diagnosed, which adds to on medical practitioners to enquire about vulvar pain, particularly their distress and confusion. pain with sex, when taking a sexual or reproductive health history. Objective Vulvodynia The aim of this article is to inform health providers about the Vulvodynia is defined by the International Society for the Study assessment and management of LPV. of Vulvovaginal Disease (ISSVD) as ‘chronic vulvar discomfort, most often described as burning pain, occurring in the absence Discussion of relevant findings or a specific, clinically identifiable, neurologic 4 Diagnosis is based on history. Examination is used to support disorder’. It is diagnosed when other causes of vulvar pain have the diagnosis.
    [Show full text]
  • Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia
    238 Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia Lori A. Brotto, PhD, Paul Yong, MD, Kelly B. Smith, PhD, and Leslie A. Sadownik, MD Department of Gynaecology, University of British Columbia, Vancouver, BC, Canada DOI: 10.1111/jsm.12718 ABSTRACT Introduction. For many years, multidisciplinary approaches, which integrate psychological, physical, and medical treatments, have been shown to be effective for the treatment of chronic pain. To date, there has been anecdotal support, but little empirical data, to justify the application of this multidisciplinary approach toward the treatment of chronic sexual pain secondary to provoked vestibulodynia (PVD). Aim. This study aimed to evaluate a 10-week hospital-based treatment (multidisciplinary vulvodynia program [MVP]) integrating psychological skills training, pelvic floor physiotherapy, and medical management on the primary outcomes of dyspareunia and sexual functioning, including distress. Method. A total of 132 women with a diagnosis of PVD provided baseline data and agreed to participate in the MVP. Of this group, n = 116 (mean age 28.4 years, standard deviation 7.1) provided complete data at the post-MVP assessment, and 84 women had complete data through to the 3- to 4-month follow-up period. Results. There were high levels of avoidance of intimacy (38.1%) and activities that elicited sexual arousal (40.7%), with many women (50.4%) choosing to focus on their partner’s sexual arousal and satisfaction at baseline. With treatment, over half the sample (53.8%) reported significant improvements in dyspareunia. Following the MVP, there were strong significant effects for the reduction in dyspareunia (P = 0.001) and sex-related distress (P < 0.001), and improvements in sexual arousal (P < 0.001) and overall sexual functioning (P = 0.001).
    [Show full text]
  • ICD-9-CM and ICD-10-CM Codes for Gynecology and Obstetrics
    Diagnostic Services ICD-9-CM and ICD-10-CM Codes for Gynecology and Obstetrics ICD-9 ICD-10 ICD-9 ICD-10 Diagnoses Diagnoses Code Code Code Code Menstral Abnormalities 622.12 Moderate Dysplasia Of Cervix (CIN II) N87.2 625.3 Dysmenorrhea N94.6 Menopause 625.4 Premenstrual Syndrome N94.3 627.1 Postmenopausal Bleeding N95.0 626.0 Amenorrhea N91.2 627.2 Menopausal Symptoms N95.1 626.1 Oligomenorrhea N91.5 627.3 Senile Atrophic Vaginitis N95.2 626.2 Menorrhagia N92.0 627.4 Postsurgical Menopause N95.8 626.4 Irregular Menses N92.6 627.8 Perimenopausal Bleeding N95.8 626.6 Metrorrhagia N92.1 Abnormal Pap Smear Results 626.8 Dysfunctional Uterine Bleeding N93.8 795.00 Abnormal Pap Smear Result, Cervix R87.619 Disorders Of Genital Area 795.01 ASC-US, Cervix R87.610 614.9 Pelvic Inflammatory Disease (PID) N73.9 795.02 ASC-H, Cervix R87.611 616.1 Vaginitis, Unspecified N76.0 795.03 LGSIL, Cervix R87.612 616.2 Bartholin’s Cyst N75.0 795.04 HGSIL, Cervix R87.613 Cervical High-Risk HPV DNA 616.4 Vulvar Abscess N76.4 795.05 R87.810 Test Positive 616.5 Ulcer Of Vulva N76.6 Unsatisfactory Cervical 795.08 R87.615 616.89 Vaginal Ulcer N76.5 Cytology Sample 623.1 Leukoplakia Of Vagina N89.4 795.10 Abnormal Pap Smear Result, Vagina R87.628 Vaginal High-Risk HPV DNA 623.5 Vaginal Discharge N89.8 795.15 R87.811 Test Positive 623.8 Vaginal Bleeding N93.9 Disorders Of Uterus And Ovary 623.8 Vaginal Cyst N89.8 218.9 Uterine Fibroid/Leiomyoma D25.9 Noninflammatory Disorder 623.9 N89.9 Of Vagina 256.39 Ovarian Failure E28.39 624.8 Vulvar Lesion N90.89 256.9 Ovarian
    [Show full text]
  • How to Evaluate Vaginal Bleeding and Discharge
    How to Evaluate Vaginal Bleeding and Discharge Is the bleeding normal or abnormal? When does vaginal discharge reflect something as innocuous as irritation caused by a new soap? And when does it signal something more serious? The authors’ discussion of eight actual patient presentations will help you through the next differential diagnosis for a woman with vulvovaginal complaints. By Vincent Ball, MD, MAJ, USA, Diane Devita, MD, FACEP, LTC, USA, and Warren Johnson, MD, CPT, USA bnormal vaginal bleeding or discharge is typically due to either inadequate levels of estrogen one of the most common reasons women or a persistent corpus luteum. Structural causes of come to the emergency department.1,2 bleeding include leiomyomas, endometrial polyps, or Because the possible underlying causes malignancy. Infectious etiologies include pelvic in- Aare diverse, the patient’s age, key historical factors, flammatory disease (PID). Additionally, a variety of and a directed physical examination are instrumental bleeding dyscrasias involving platelet or clotting fac- in deciding on diagnosis and treatment. This article tors can complicate the normal menstrual period. Iat- will review some common case presentations of rogenic causes of vaginal bleeding include hormone nonpregnant female patients with abnormal vaginal replacement therapy, steroid hormone contraception, bleeding, inflammation, or discharge. and contraceptive intrauterine devices.3-5 Anovulatory bleeding is common in perimenar- ABNORMAL VAGINAL BLEEDING chal girls as a result of an immature hypothalamic- To ensure appropriate patient management, “Is she pituitary axis and in perimenopausal women due to pregnant?” should be the first question addressed, declining levels of estrogen. During reproductive since some vulvovaginal signs and symptoms will years, dysfunctional uterine differ in significance and urgency depending on the bleeding (DUB) is the most >>FAST TRACK<< answer.
    [Show full text]
  • Women's Health Concerns
    WOMEN’S HEALTH Natalie Blagowidow. M.D. CONCERNS Gynecologic Issues and Ehlers- Danlos Syndrome/Hypermobility • EDS is associated with a higher frequency of some common gynecologic problems. • EDS is associated with some rare gynecologic disorders. • Pubertal maturation can worsen symptoms associated with EDS. Gynecologic Issues and Ehlers Danlos Syndrome/Hypermobility •Menstruation •Menorrhagia •Dysmenorrhea •Abnormal menstrual cycle •Dyspareunia •Vulvar Disorders •Pelvic Organ Prolapse Puberty and EDS • Symptoms of EDS can become worse with puberty, or can begin at puberty • Hugon-Rodin 2016 series of 386 women with hypermobile type EDS. • 52% who had prepubertal EDS symptoms (chronic pain, fatigue) became worse with puberty. • 17% developed symptoms of EDS with puberty Hormones and EDS • Conflicting data on effects of hormones on connective tissue, joint laxity, and tendons • Estriol decreases the formation of collagen in tendons following exercise • Joint laxity increases during pregnancy • Studies (Non EDS) • Heitz: Increased ACL laxity in luteal phase • Park: Increased knee laxity during ovulation in some, but no difference in hormone levels among all (N=26) Menstrual Cycle Hormonal Changes GYN Issues EDS/HDS:Menorrhagia • Menorrhagia – heavy menstrual bleeding 33-75%, worst in vEDS • Weakness in capillaries and perivascular connective tissue • Abnormal interaction between Von Willebrand factor, platelets and collagen Menstrual cycle : Endometrium HORMONAL CONTRACEPTIVE OPTIONS GYN Menorrhagia: Hormonal Treatment • Oral Contraceptive Pill • Progesterone only medication • Progesterone pill: Norethindrone • Progesterone long acting injection: Depo Provera • Long Acting Implant: Etonorgestrel • IUD with progesterone Hormonal treatment for Menorrhagia •Hernandez and Dietrich, EDS adolescent population in menorrhagia clinic •9/26 fine with first line hormonal medication, often progesterone only pill •15/26 required 2 or more different medications until found effective one.
    [Show full text]
  • Vaginal Atrophy (VVA)
    Information Sheet Vulvovaginal symptoms after menopause Key points • Vulvovaginal symptoms are numerous and varied and result from declining oestrogen levels. • Investigate any post- menopausal bleeding or malodorous discharge. • Management includes lifestyle changes as well as prescription and non- prescription medications. • As women age they will experience changes to their vagina and urinary system largely due to decreasing levels of the hormone oestrogen. • The changes, which may cause dryness, irritation, itching and pain with intercourse1-3 are known as the genito-urinary syndrome of menopause (GSM) and can affect up to 50% of postmenopausal women4. GSM was previously known as atrophic vaginitis or vulvovaginal atrophy (VVA). • Unlike some menopausal symptoms, such as hot flushes, which may disappear as time passes; genito-urinary problems often persist and may progress with time. Genito-urinary symptoms are associated both with menopause and with ageing4. • Changes in vaginal and urethral health occur with natural and surgical menopause, as well as after treatments for certain medical conditions (Please refer to AMS Information Sheet Vaginal health after breast cancer: A guide for patients). Why is oestrogen important for vaginal health? • The vaginal area needs adequate levels of oestrogen to maintain tissue integrity. • The vaginal epithelium contains oestrogen receptors which, when stimulated by the hormone, keep the walls thick and elastic. • When the amount of oestrogen in the body decreases this is commonly associated with dryness of the vulva and vagina. • A normal pre-menopausal vagina is naturally acidic, but with menopause it may become more alkaline, increasing susceptibility to urinary tract infections. A number of factors, including low oestrogen levels, have been implicated in the development of UTIs4-7 and vaginitis8-9 in postmenopausal women.
    [Show full text]
  • The Older Woman with Vulvar Itching and Burning Disclosures Old Adage
    Disclosures The Older Woman with Vulvar Mark Spitzer, MD Itching and Burning Merck: Advisory Board, Speakers Bureau Mark Spitzer, MD QiagenQiagen:: Speakers Bureau Medical Director SABK: Stock ownership Center for Colposcopy Elsevier: Book Editor Lake Success, NY Old Adage Does this story sound familiar? A 62 year old woman complaining of vulvovaginal itching and without a discharge self treatstreats with OTC miconazole.miconazole. If the only tool in your tool Two weeks later the itching has improved slightly but now chest is a hammer, pretty she is burning. She sees her doctor who records in the chart that she is soon everyyggthing begins to complaining of itching/burning and tells her that she has a look like a nail. yeast infection and gives her teraconazole cream. The cream is cooling while she is using it but the burning persists If the only diagnoses you are aware of She calls her doctor but speaks only to the receptionist. She that cause vulvar symptoms are Candida, tells the receptionist that her yeast infection is not better yet. The doctor (who is busy), never gets on the phone but Trichomonas, BV and atrophy those are instructs the receptionist to call in another prescription for teraconazole but also for thrthreeee doses of oral fluconazole the only diagnoses you will make. and to tell the patient that it is a tough infection. A month later the patient is still not feeling well. She is using cold compresses on her vulva to help her sleep at night. She makes an appointment. The doctor tests for BV.
    [Show full text]
  • The Woman with Postmenopausal Bleeding
    THEME Gynaecological malignancies The woman with postmenopausal bleeding Alison H Brand MD, FRCS(C), FRANZCOG, CGO, BACKGROUND is a certified gynaecological Postmenopausal bleeding is a common complaint from women seen in general practice. oncologist, Westmead Hospital, New South Wales. OBJECTIVE [email protected]. This article outlines a general approach to such patients and discusses the diagnostic possibilities and their edu.au management. DISCUSSION The most common cause of postmenopausal bleeding is atrophic vaginitis or endometritis. However, as 10% of women with postmenopausal bleeding will be found to have endometrial cancer, all patients must be properly assessed to rule out the diagnosis of malignancy. Most women with endometrial cancer will be diagnosed with early stage disease when the prognosis is excellent as postmenopausal bleeding is an early warning sign that leads women to seek medical advice. Postmenopausal bleeding (PMB) is defined as bleeding • cancer of the uterus, cervix, or vagina (Table 1). that occurs after 1 year of amenorrhea in a woman Endometrial or vaginal atrophy is the most common cause who is not receiving hormone therapy (HT). Women of PMB but more sinister causes of the bleeding such on continuous progesterone and oestrogen hormone as carcinoma must first be ruled out. Patients at risk for therapy can expect to have irregular vaginal bleeding, endometrial cancer are those who are obese, diabetic and/ especially for the first 6 months. This bleeding should or hypertensive, nulliparous, on exogenous oestrogens cease after 1 year. Women on oestrogen and cyclical (including tamoxifen) or those who experience late progesterone should have a regular withdrawal bleeding menopause1 (Table 2).
    [Show full text]
  • Vulvovaginal Atrophy: a Common—And Commonly Overlooked— Problem Mary H
    The Warren Alpert Medical School of Brown University GERI A TRI C S FOR THE Division of Geriatrics PR ac TI C ING PHYSICIAN Quality Partners of RI Department of Medicine EDITED B Y AN A Tuya FU LTON , MD Vulvovaginal Atrophy: A Common—and Commonly Overlooked— Problem Mary H. Hohenhaus, MD, FACP Mrs. K is a 67-year-old woman presenting for a brief All postmenopausal women are at risk for vaginal atrophy. follow-up visit. You treated her for an E. coli urinary Smokers are more estrogen deficient compared with nonsmok- tract infection last month, but she feels well today and ers and may be at higher risk. Engaging in regular sexual activ- offers no complaints. Her blood pressure and lipids ity, whether through intercourse or masturbation, appears to are well controlled on low doses of a single antihyper- decrease risk, possibly through increased blood flow. Women tensive and a lipid lowering agent. She still struggles using anti-estrogen medications, such as aromatase inhibitors with smoking, but has cut down to a few cigarettes a for adjuvant treatment of breast cancer, are more likely to experi- day. She also reports her husband has finally turned ence severe symptoms. over the family business to their children, and they Women may not volunteer symptoms related to vulvovagi- are enjoying spending more time together. When you nal atrophy. The symptomatic woman can experience vaginal ask if there is anything else she needs, she hesitates dryness, burning, and pruritus; yellow, malodorous discharge; for a moment before asking, “Is there anything I can urinary frequency and urgency; and pain during intercourse and do to make sex more comfortable?” bloody spotting afterward.
    [Show full text]
  • Vulvodynia: What We Know and Where We Should Be Going
    SYSTEMATIC REVIEW,META-ANALYSIS,NARRATIVE REVIEW Vulvodynia: What We Know and Where We Should Be Going Logan M. Havemann, BA,1 David R. Cool, PhD,1,2 Pascal Gagneux, PhD,3 Michael P.Markey, PhD,4 Jerome L. Yaklic, MD, MBA,1 Rose A. Maxwell, PhD, MBA,1 Ashvin Iyer, MS,2 and Steven R. Lindheim, MD, MMM1 evolving definitions, and unidentified pathogenesis of disease. Objective: The aim of the study was to review the current nomenclature The pathogenesis of VVD remains largely unknown and is likely and literature examining microbiome cytokine, genomic, proteomic, and multifactorial. Recent research has focused largely on an inflam- glycomic molecular biomarkers in identifying markers related to the under- matory pathogenesis, and our current understanding suggests an standing of the pathophysiology and diagnosis of vulvodynia (VVD). initial vaginal insult with infection1 followed by an inflammatory Materials and Methods: Computerized searches of MEDLINE and response10 that may result in peripheral and central pain sensitiza- PubMed were conducted focused on terminology, classification, and tion, mucosal nerve fiber proliferation, hypertrophy, hyperplasia, “ ” omics variations of VVD. Specific MESH terms used were VVD, and enhanced systemic pain perception.11 With advancements in vestibulodynia, metagenomics, vaginal fungi, cytokines, gene, protein, in- our ability to measure transcriptomic markers of disease, as well flammation, glycomic, proteomic, secretomic, and genomic from 2001 to as the progress in mapping the human genome and how variations 2016. Using combined VVD and vestibulodynia MESH terms, 7 refer- affect disease states, new avenues of research in the pathogenesis ences were identified related to vaginal fungi, 15 to cytokines, 18 to gene, of VVD can now be explored including the potential role for 43 to protein, 38 to inflammation, and 2 to genomic.
    [Show full text]
  • Common Causes of Chronic Pelvic Pain Diagnoses Description Dysmenorrhea • Dysmenorrhea Is Pain During Menstruation That Is Not Associated with Well-Defined Pathology
    Common Causes of Chronic Pelvic Pain Diagnoses Description Dysmenorrhea • Dysmenorrhea is pain during menstruation that is not associated with well-defined pathology. • Primary dysmenorrhea: cramping pain in the lower abdomen, originating in the uterus • Secondary dysmenorrhea: painful menstruation resulting from pelvic pathology such as endometriosis • Dysmenorrhea is considered a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual or emotional consequences. Dyspareunia • Dyspareunia is characterized as pain before, during, or after sexual activity. It is not solely caused by lack of lubrication. • Dyspareunia may present as superficial, deep, or both. • Superficial: discomfort at entry of vaginal introitus • Deep: complaint of pain or discomfort on deeper penetration • Causes of dyspareunia include atrophic vaginitis, vulvar vestibulitis, lichen sclerosis, endometriosis, scar adhesions, and trauma. Endometriosis • Endometriosis is when endometrial tissue typically found in the uterus is found outside of the uterus. • Most women with endometriosis experience pelvic pain during their menstrual cycles but many also have pain that is unrelated to their period. Fibromyalgia syndrome • Fibromyalgia affects the muscles, tendons, ligaments, and soft tissues of the body. • Fibromyalgia causes pain throughout entire body, including the vulvar and pelvic/hip region. • Symptoms of fibromyalgia include extreme fatigue, sleep disturbances, burning sensations throughout body. Interstitial cystitis/ • Interstitial cystitis is characterized by: painful bladder syndrome o Urinary urgency: feeling the need to urinate o Urinary frequency: urinating up to every 5-10 minutes o Pelvic Pain: in the vulva, pain with intercourse, or pain in the lower back and hips. • Many foods and drinks may trigger interstitial cystitis. Fruit juices such as oranges, cranberry and tomato are bladder irritants.
    [Show full text]