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Neuromodulation in the Management of Allergic Chronic Vaginitis

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Neuromodulation in the Management of Allergic Chronic Vaginitis em & yst Se S xu e a v l i t D c i Reproductive System & Sexual s u o Theodoropoulos, et al., Reprod Syst Sex Disord 2016, 5:4 d r o d r e p r e DOI: 10.4172/2161-038X.1000197 s R Disorders: Current Research ISSN: 2161-038X Review Article OMICS International Neuromodulation in the Management of Allergic Chronic Vaginitis Demetrios S Theodoropoulos1*, Alexandra P Michalopoulou2, Niamh A Cullen3 and Colleen K Stockdale4 1Allergy Associates of La Crosse, La Crosse, Wisconsin, USA 2School of Philosophy and Social Studies, University of Crete, Rethymnon, Greece 3Private practice, Allergy Associates of La Crosse, USA 4Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA *Corresponding author: Theodoropoulos DS, Allergy Associates of La Crosse, 2727 Midwest Drive, Onalaska, Wisconsin 54650, USA, Tel: +1 608-782-2027; Fax: 001-608-782-6172; E-mail: [email protected] Rec date: November 24, 2016; Acc date: December 19, 2016; Pub date: December 26, 2016 Copyright: © 2016 Theodoropoulos DS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Chronic vaginitis (CV) affects 16% of women. While a number of distinct diagnoses account for the underlying causes of CV, allergic inflammation is also present in a significant number of cases and may range from 25 to 54% of CV patients. Allergic inflammation in CV is encountered as a result of: i) direct sensitization of the vaginal mucosa to latex, local products, Candida, bacteria, etc.; ii) inhalant allergy compounding the chronic vaginitis syndrome; iii) immune cell activation secondary to neurogenic inflammation in the context of chronic neuropathic pain. Despite the varying nature of specific neuro-immune interactions, chronic pain/irritation remains a cardinal feature of CV which needs to be addressed as a priority independently of specific gynecological or allergy-modifying interventions. This is necessary not only for reasons of symptom relief but also because long-term neuronal changes due to inflammation and chronic pain have a profound effect on the course of CV by potentiating adverse pro-inflammatory and degenerating processes. The pathophysiology of these processes and their alteration by means of neuromodulators is presented with a view of long-term control of chronic pain and neurogenic inflammation. Special emphasis is placed on gamma-aminobutyric acid-served pathways, the use of tricyclic antidepressants, serotonin- reuptake inhibitors and certain antihistamines with anti-serotoninergic properties. Keywords: Chronic vaginitis; Allergy; Immunotherapy; Compared to the general population, the prevalence of atopic diathesis Inflammation; Neuropathic pain appears to be nearly equal to the presence of clinical allergy among women with CV. Introduction Allergic sensitization to Candida as well as successful treatment of Chronic vaginitis (CV), unrelated to infection or trauma, is recurrent vulvovaginal candidiasis with Candida immunotherapy has common in the general population and is one of the most frequent been described [5,6]. Sensitization to latex and to a variety of local reasons for visits to gynecologists. Chronic vulvar and vaginal medications and other products has also been presented along with a complaints are known to be under-reported and under-diagnosed. It is variety of contact-type sensitizations [7]. estimated that at least 16% of women will experience chronic vaginal In addition to locally presented and locally acting sensitizers, a and/or vulvar pain for at least three to six months, which is the clinical clinically significant association between CV and allergic airway definition of vulvodynia [1]. For chronic pruritus, dysesthesia, responses to inhalants has also been established and specific paresthesia or other types of discomfort there are no valid data. The mechanisms to explain this association have been proposed [8,9]. term CV represents a multifactorial and highly heterogeneous Additionally, selection criteria for CV patients likely to benefit from condition, which may result from several distinct conditions or their allergen immunotherapy have been identified and the long-term combination [2,3]. Allergies often co-exist with CV. It is estimated that outcome of such selection has been assessed as favorable [10]. In 25-54% of women with CV carry either a current diagnosis or a past general, CV patients presenting with somatic type responses, that is, history of at least one allergic disease clinical manifestation [2]. The surface symptoms dominated by pruritus or other mucosal or skin concurrence of allergy and CV exceeds the expected rates. The irritation, but not deep visceral pain, tend to respond earlier to allergen prevalence of atopic diathesis in the general population, that is, the immunotherapy, require fewer courses of antibiotics and antifungals, natural ability to mount an IgE response and exhibit immediate type and are often able to stop their long-term pain-control medication. skin sensitivity to allergens is assessed as 50%. However, manifestation These patients tend to suffer primarily from recurrent vulvovaginal of allergic diseases in the general population occurs at significantly candidiasis symptoms, although no more than 32% of allergic CV lower rates than those reported in the CV-affected segment of the patients with recurrent vulvovaginal candidiasis demonstrated population. Expected rates for allergic disease in the general evidence of Candida sensitization [10]. Alternatively, allergen population are generally reported as 10-20% for allergic rhinitis and immunotherapy has been less rewarding for patients with visceral type 5-7% for asthma, and the one-time incidence of chronic urticaria may pain or neuropathic pain. Furthermore, the vast majority of CV be up to 20% [4]. While pre-existing atopic disposition to mount IgE patients who present with either visceral or neuropathic pain remain responses to allergens represents a potential for the development of on long-term pain control regimens 3-5 years into allergen allergic sensitization, it does not necessarily lead to clinical expression. immunotherapy. The gynecological diagnoses in this second category Reprod Syst Sex Disord, an open access journal Volume 5 • Issue 4 • 1000197 ISSN:2161-038X Citation: Theodoropoulos DS, Michalopoulou AP, Cullen NA, Stockdale CK (2016) Neuromodulation in the Management of Allergic Chronic Vaginitis . Reprod Syst Sex Disord 5: 197. doi:10.4172/2161-038X.1000197 Page 2 of 7 vary widely and include (in order of frequency) vestibulodynia, in general in CV, the prevalence of asthma among patients with allergic recurrent vulvovaginal candidiasis, bacterial vaginosis, contact CV is quite low [8,10]. dermatitis, lichen simplex, lichen sclerosus and desquamative The pharmacology of GABAergic activity is expanding. inflammatory vaginitis, and can appear in combinations [10]. Neither Traditionally, drugs are categorized based on the type of GABA the kinds of allergens nor the diagnoses of allergic diseases appear to receptor involved in their action, but this area is expanding too. be specific to the “pruritic” versus “deep pain” groups or when allergic GABA agonists include barbiturates, benzodiazepines, propofol and CV is compared to the general population allergies [10]. It is for this A ethanol. GABA agonists include, among others, baclofen, a skeletal reasons that chronic pain in CV is discussed as a result of B muscle relaxant often used in the management of vulvodynia including inflammation as well as an independent factor likely to lead to: CV symptoms, and, notoriously, γ-hydroxy-butyric acid, a precursor of • Perpetuation of CV in spite of specific gynecological treatment, GABA and also a “date-rape” drug. Research in the area of GABA • Chronic ill health, reuptake inhibitors is growing as well. GABA-transaminase inhibitors • Chronic immunological changes which hinder the immune famously include valproate and vigabatrin, both of which have been modification intended by immunotherapy. used in vulvodynia including CV as well as in other forms of chronic pain with a neuropathic component. The main stay of long-term Effective pain management in CV is viewed not only as symptom management of GABA-dependent activity in vulvodynia including CV control but also as a primary therapeutic objective are the GABA analogues gabapentin and pregabalin. Pro-inflammatory cytokines and gamma-aminobutyric acid- While the efferent effect of impaired GABA activity is yet to be studied (i.e., increased sympathetic outflow through the PVN, dependent responses neuropeptide production contributing to peripheral neurogenic It has been long recognized that gamma-aminobutyric acid (GABA) inflammation, epithelial GABA-dependent inflammatory activity, is the main inhibitory neurotransmitter in the central nervous system. effects of GABA on stem cells, effects on resident immune cells, etc.) it It reduces nerve excitability by suppressing calcium ion influx into the is the afferent direction of inflammatory responses and their effect on cytoplasm. It allows influx of negatively charged chloride ions and GABA production which constitutes a therapeutic priority. In this outflow of positively charged potassium ions [11]. These actions result context, gabapentin, pregabalin, benzodiazepines, vigabatrin, valproate in hyperpolarization
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