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Singh L, Kumari K, Sharma S. Vulvar dermatoses-Can a pattern-based approach improve diagnostic yield? J Cutan Pathol 2023; 50:364-370. [PMID: 36421982 DOI: 10.1111/cup.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/09/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vulvar dermatoses (VD) pose a formidable challenge to clinicians and pathologists owing to various factors. The factors included are the histopathological heterogeneity of the vulva, moist and frictional environment, and the limited experience of gynecologists and general histopathologists in this field. To address this issue, the International Society for the Study of Vulvovaginal Disease (ISSVD) proposed a histopathological tissue reaction-based classification system for VD. Therefore, we attempted to study the utility of the 2006 ISSVD classification in reporting VD. We further evaluated if a dermatopathologist review could improve the diagnostic yield. MATERIALS AND METHODS The vulvar biopsy reports (N = 106) were retrieved from histopathology case files, out of which benign non-infectious conditions (n = 55) were included in the study. The diagnosis retrieved from the case files was considered the initial diagnosis. Three dermatopathologists reviewed each biopsy, and a tissue reaction pattern/diagnosis was assigned as per ISSVD 2006, and this was considered a review diagnosis. The initial and review diagnoses were compared and analyzed. We further studied and analyzed the effect of the dermatopathologist's review on the diagnostic yield. RESULTS The sclerotic pattern (34.6%) was the commonest tissue reaction pattern, followed by spongiotic (18%) and acanthotic patterns (14.5%) independently or in combination. The non-specific/descriptive report rate was significantly decreased following 2006 ISSVD and the dermatopathologist's review (83.6% vs.1.8%). CONCLUSION Rendering tissue reaction patterns to vulvar biopsies will enable a comprehensive understanding of lesions and aid in clinically relevant reporting. In addition, dermatopathologists' review of difficult vulvar biopsies increases the diagnostic yield.
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Affiliation(s)
- Lavleen Singh
- University College of Medical Sciences, New Delhi, India
| | - Kalpana Kumari
- University College of Medical Sciences, New Delhi, India
| | - Sonal Sharma
- University College of Medical Sciences, New Delhi, India
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2
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Vulvar dermatoses: a cross-sectional 5-year study. Experience in a specialized vulvar unit. An Bras Dermatol 2022; 97:747-756. [PMID: 36089549 PMCID: PMC9582872 DOI: 10.1016/j.abd.2021.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022] Open
Abstract
Background Vulvar diseases are common in the general population and have a negative impact on the quality of life. Objectives To describe our experience as dermatologists in the management of vulvar dermatosis consultations. Methods A retrospective observational study was conducted with patients who attended monographic vulvar consultations over a 5-year period. Clinical information was obtained from the patient’s charts. Results 148 women were studied. Their mean age was 43.24 years (standard deviation: 15.15 years), with ages ranging from 4 months to 80 years. 53.4% of patients took between 2 and 5 years to seek medical attention for the first time. The most frequent diagnosis was lichen sclerosus (41.9%), irritative eczema of the vulva (14.9%), and lichen simplex chronicus (10.1%). 83.8% reported anogenital itching, 66.2% pain, and 45.9% dyspareunia. The most frequently prescribed treatment was ultra-potent topical corticosteroids (clobetasol propionate; 41.2%). Patients with lichen sclerosus were significantly older than those who presented with any of the other diseases. No differences were found in terms of either the time of disease evolution or in symptom presentation. Study limitations Retrospective study. Vulvar diseases with an infectious cause are usually managed in primary care, therefore, were not included. All patients were recruited from a single private hospital which limits the comparisons with the public health system. Conclusions Vulvar diseases frequently occur and are associated with high morbidity. It is essential to promote the development of specific vulvar consultations in hospitals. Specialties such as dermatology, gynecology, urology, or physiotherapy must be part of these units.
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3
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Rivera S, Dykstra C, Flood A, Herbenick D, DeMaria AL. "Worse Than Disappointing": Prediagnostic Health Care Challenges of Women With Inflammatory Vulvar Dermatoses. J Low Genit Tract Dis 2022; 26:53-59. [PMID: 34928253 DOI: 10.1097/lgt.0000000000000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate challenges women face before inflammatory vulvar dermatosis diagnosis to guide interventions for improving time to diagnosis and health care experiences. MATERIALS AND METHODS The present analysis was part of a larger study exploring sexual health and quality of life of women with vulvar and nonvulvar inflammatory dermatoses, evaluated via a 20-minute web-based survey. One open-response item asked participants to "briefly describe any challenges you faced with regards to health care or health care providers in the time when you were seeking a diagnosis"; this item informed the present study. Eligible participants were women older than 18 years, living in the United States, with diagnosis of an inflammatory vulvar dermatosis persisting at least 1 month. Participants (n = 118) had a mean age of 46.55 ± 15.35 years, and 64% (n = 75) had lichen sclerosus. RESULTS Provider-based challenges consisted of insensitive communication and ascribing physical symptoms to mental health issues, self-harm, or other factors. System-based challenges included confusing referral networks, limited specialist access, and widespread lack of provider education. Personal challenges for participants seeking care included feelings of embarrassment and reduced health care efficacy. Challenges led to emotional response and impact for participants, characterized by negative (e.g., distrust in the medical system) or positive (e.g., self-advocacy efforts, strong social media communities) outcomes. CONCLUSIONS Findings provide unique insights into the challenges women experience before inflammatory vulvar dermatosis diagnosis. This study creates new knowledge exploring the diagnostic journey accompanying inflammatory vulvar dermatoses and contributes practically to clinical and research needs of this understudied population.
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Affiliation(s)
- Sydney Rivera
- Indiana University School of Medicine, Indianapolis, IN
| | - Chandler Dykstra
- Marian University College of Osteopathic Medicine, Indianapolis, IN
| | - Anna Flood
- School of Health Sciences, Purdue University, West Lafayette, IN
| | - Debby Herbenick
- Center for Sexual Health Promotion, School of Public Health, Indiana University, Bloomington, IN
| | - Andrea L DeMaria
- Department of Public Health, Purdue University, West Lafayette, IN
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4
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Migda M, Migda MS, Migda B, Maleńczyk M. The usefulness of high-frequency ultrasonography in the evaluation of vulvar dermatoses in postmenopausal women - a preliminary report. J Ultrason 2020; 19:282-286. [PMID: 32021710 PMCID: PMC6988568 DOI: 10.15557/jou.2019.0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction The vulva is an external female genital organ with complex anatomy and histology. In postmenopausal women, this region is at particular risk of different types of conditions known as dermatoses. Materials and methods We assessed benign vulvar skin lesions using high-frequency 48 MHz ultrasound transducer (DermaView) prior to biopsy or excision. We compared ultrasonographic images with histology. Results We assessed benign vulvar lesions such as folliculitis, condylomata acuminatum, lichen sclerosus and vulvar intraepithelial neoplasia. We presented typical high-frequency images of these pathologies and compared them with histological images. Conclusion Our preliminary study confirms that high-frequency ultrasonography is a useful tool in the assessment of vulvar pathologies, especially before surgical excision. A precise visualization of certain pathologies like folliculitis, lichen sclerosus, condylomata and vulvar intraepithelial neoplasia is possible.
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Affiliation(s)
- Michał Migda
- Clinical Unit of Obstetrics, Women's Disease and Gynecological Oncology, United District Hospital, Collegium Medicum University of Nicolaus Copernicus in Toruń, Torun, Poland.,Civis Vita Medical Center Torun, Poland
| | | | - Bartosz Migda
- Department of Diagnostic Imaging, Second Faculty of Medicine with the English Division and the Physiotherapy Division, Medical University of Warsaw, Warsaw, Poland
| | - Marek Maleńczyk
- Clinical Unit of Obstetrics, Women's Disease and Gynecological Oncology, United District Hospital, Collegium Medicum University of Nicolaus Copernicus in Toruń, Torun, Poland
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5
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Merola JF, Ghislain PD, Dauendorffer JN, Potts Bleakman A, Brnabic AJM, Burge R, Riedl E. Ixekizumab improves secondary lesional signs, pain and sexual health in patients with moderate-to-severe genital psoriasis. J Eur Acad Dermatol Venereol 2020; 34:1257-1262. [PMID: 31919919 PMCID: PMC7318177 DOI: 10.1111/jdv.16181] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/13/2019] [Indexed: 11/29/2022]
Abstract
Background Epithelial surface disruption in genital psoriatic lesions may manifest as erosions, fissures and/or ulcers, causing pain and significantly impacting a patient's sexual health. Objective To evaluate the impact of erosions, fissures and/or ulcers in genital psoriatic lesions on pain and sexual activity in patients with moderate‐to‐severe genital psoriasis (GenPs) and treatment responses to ixekizumab vs. placebo until Week 12. Methods This post hoc subgroup analysis of patients presenting with and without erosions, fissures and/or ulcers in genital lesions from a phase IIIb multicentre, randomized, double‐blind, placebo‐controlled study (IXORA‐Q; NCT02718898) in 149 adults with moderate‐to‐severe GenPs treated with subcutaneous ixekizumab (80 mg every 2 weeks; n = 75) or placebo (n = 74) evaluated outcomes for clinician‐rated GenPs severity (static Physician's Global Assessment of Genitalia; sPGA‐G) and patient‐reported genital pain and itch (Genital Psoriasis Symptoms Scale; GPSS) and sexual health (Genital Psoriasis Sexual Frequency Questionnaire; GenPs‐SFQ). Results At baseline, 38% (n = 57) of patients presented with genital erosions, fissures and/or ulcers independent of overall body surface area involvement (<10% or ≥10%). These signs were associated with higher scores for disease severity (sPGA‐G) and pain (GPSS) but not sexual health (GenPs‐SFQ). Complete resolution of these signs was observed in 62% of ixekizumab‐treated patients (25% for placebo) at Week 1 and 83% (21% for placebo) at Week 12. Patients treated with ixekizumab reported significant improvements in pain, itch, disease severity and sexual health over 12 weeks compared to placebo and irrespective of the presence/absence of genital erosions, fissures and/or ulcers at baseline. Conclusion Ixekizumab led to rapid and sustained resolution of erosions, fissures and/or ulcers and significant improvements in GenPs severity, genital pain and sexual health. Ixekizumab may help to improve the well‐being of patients with GenPs.
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Affiliation(s)
- J F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P-D Ghislain
- Department of Dermatology, Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | | | - R Burge
- Eli Lilly and Company, Indianapolis, IN, USA
| | - E Riedl
- Eli Lilly and Company, Indianapolis, IN, USA.,Department of Dermatology, Medical University of Vienna, Vienna, Austria
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6
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Cassol-Spanemberg J, Blanco-Carrión A, Rodríguez-de Rivera-Campillo ME, Estrugo-Devesa A, Jané-Salas E, López-López J. Cutaneous, genital and oral lichen planus: A descriptive study of 274 patients. Med Oral Patol Oral Cir Bucal 2019; 24:e1-e7. [PMID: 30573709 PMCID: PMC6344000 DOI: 10.4317/medoral.22656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/13/2018] [Indexed: 12/20/2022] Open
Abstract
Background Lichen planus (LP) is a chronic autoimmune disease that affects the oral mucosa as well as the skin, genital mucosa and other sites. Objective: to evaluate the correlation between oral, genital and cutaneous lichen planus, in a sample of LP patients. Material and Methods This descriptive study reviewed 274 clinical histories of patients, who all presented histological confirmation of lichen planus verified by a pathologist, attending research centers in Barcelona. Results A total of 40 LP patients (14.59%) presented genital lesions. Of 131 patients with cutaneous LP (47.8%), the most commonly affected zones were the body’s flexor surfaces, representing 60.1% of cases. 24% of patients (n=55) related the start of the lesions with previous stress events. Of the 131 subjects with cutaneous lesions, 19% (n=25) also presented oral lichen planus (OLP). Of the total sample, 53.6% (n=147) of patients presented oral lesions. The systemic diseases most commonly associated with this patient sample were psychological problems such as stress, anxiety and depression (48%), hypertension (27%), gastric problems (12%), and diabetes (9.7%). A family history of lichen planus was found in only 2 cases (0,72%) out of the total of 274. Conclusions Any patient with OLP should undergo a thorough history and examination to investigate potential extraoral manifestations. The fact that 37 patients with OLP in this patient series were identified with simultaneous involvement at more than one site highlights the need for thorough evaluation and multidisciplinary approaches to this disease. Key words:Oral lichen planus, extra-oral manifestations, cutaneous lichen planus, genital lichen planus.
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Affiliation(s)
- J Cassol-Spanemberg
- Bellvitge University Campus, Department of Dental Medicine - School of Dentistry, Pabellón de Gobierno, C/. Feixa LLarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona - Spain,
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Sartori GC, Wicher RT, Ferreira FR, Batista VH. Most frequent dermatoses at a vulvar pathology outpatient clinic. An Bras Dermatol 2018; 93:294-296. [PMID: 29723364 PMCID: PMC5916413 DOI: 10.1590/abd1806-4841.20186784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/14/2017] [Indexed: 11/27/2022] Open
Abstract
The vulva corresponds to the external female genitalia. Special features of this region favor a wide range of diseases, whose knowledge allows for better clinical management, impacting on the quality of life. This is a cross-sectional and descriptive study carried out at a vulvar pathology outpatient clinic, between May and December/ 2015. Data obtained from a standard form included demographic parameters, habits, and vulvar dermatosis and allowed to identify the epidemiological profile of patients with vulvar dermatosis treated in this outpatient clinic and to determine the most prevalent dermatoses. Our results, partially concordant with the literature, provide original data that should stimulate further studies.
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Affiliation(s)
- Gabriella Cerazi Sartori
- Sector of Inter-Hospital Transportation, Núcleo de
Atendimento Unimed Tatuapé - São Paulo (SP), Brazil
| | - Rafaela Tricca Wicher
- Graduation in the Department of Medicine, Universidade de
Taubaté (UNITAU) - Taubaté (SP), Brazil
| | - Flávia Regina Ferreira
- Discipline of Dermatology, Department of Medicine, Universidade de
Taubaté (UNITAU) - Taubaté (SP), Brazil
- Service of Dermatology, Hospital Universitário de
Taubaté - Universidade de Taubaté (HUT/-UNITAU) - Taubaté (SP),
Brazil
| | - Valéria Holmo Batista
- Discipline of Gynecology and Obstetrics, Department of Medicine,
Universidade de Taubaté (UNITAU) - Taubaté (SP), Brazil
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8
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Gottlieb AB, Kirby B, Ryan C, Naegeli AN, Burge R, Potts Bleakman A, Anatchkova MD, Yosipovitch G. The Development of a Patient-Reported Outcome Measure for Assessment of Genital Psoriasis Symptoms: The Genital Psoriasis Symptoms Scale (GPSS). Dermatol Ther (Heidelb) 2017; 8:45-56. [PMID: 29204893 PMCID: PMC5825318 DOI: 10.1007/s13555-017-0213-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Patient-reported outcome measures (PROs) specific for genital psoriasis (GenPs) have not been described. METHODS In this cross-sectional, qualitative study in patients with moderate-to-severe GenPs, we sought to develop a PRO useful for GenPs symptom assessment. A literature review was performed to identify relevant psoriasis or GenPs symptoms and existing PROs that may be useful in the evaluation of symptom severity in GenPs patients. The literature review findings were discussed with clinicians, and then patients with GenPs. RESULTS Relevant psoriasis or GenPs symptoms from the literature review included itch, pain, scaling, redness/erythema, and stinging/burning. The validity of these symptoms for GenPs and potentially relevant PROs was corroborated by clinical experts. After gap analysis, a draft symptom scale consisting of Numeric Rating Scale (NRS) items was constructed. We then conducted interviews with GenPs patients (n = 20) to support content validity and use of the draft symptom NRS items in routine practice and in clinical trials. Participants identified and confirmed relevant symptoms and evaluated the utility of the draft PRO. A new PRO was developed: the Genital Psoriasis Symptoms Scale (GPSS). Cognitive debriefing and cultural adaptation/translation interviews with a second group of patients confirmed cultural appropriateness of the GPSS. CONCLUSION The GPSS may be useful for assessing symptoms before, during, and after treatment in routine clinical practice and in clinical trials involving patients with GenPs. FUNDING Eli Lilly & Company. Plain language summary available for this article.
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Affiliation(s)
- Alice B Gottlieb
- New York Medical College, Metropolitan Hospital, New York, NY, USA.
| | - Brian Kirby
- St Vincent's University Hospital, Dublin, Ireland
| | | | | | - Russel Burge
- Eli Lilly and Company, Indianapolis, IN, USA.,Winkle College of Pharmacy, Pharmacy Practice and Administrative Sciences, University of Cincinnati, Cincinnati, OH, USA
| | | | | | - Gil Yosipovitch
- Miller School of Medicine, University of Miami, Miami, FL, USA
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9
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Sand FL, Thomsen SF. Skin diseases of the vulva: eczematous diseases and contact urticaria. J OBSTET GYNAECOL 2017; 38:295-300. [DOI: 10.1080/01443615.2017.1329283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Freja Lærke Sand
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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10
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Abstract
Vulvovaginal lichen planus is a type of chronic inflammatory dermatosis of the vulva, usually seen as a part of widespread lichen planus. The common clinical types of vulval lichen planus include papulosquamous, erosive and pigmented types. Hypertrophic lichen planus of the vulva is a rare entity. We report a case of hypertrophic lichen planus of the vulva which clinically simulated genital warts.
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Affiliation(s)
- Anupa Mary Job
- Department of Dermatology, St John’s Medical College, Bangalore, India
| | - Sowmya Kaimal
- Department of Dermatology, St John’s Medical College, Bangalore, India
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Kelekçi KH, Özyurt S, Özkan B, Karaca Ş, Karakuzu A, Bilgin İ. The Impact of Inflammatory and Infectious Diseases of Vulvar on Quality of Life. J Menopausal Med 2016; 22:131-138. [PMID: 28119892 PMCID: PMC5256362 DOI: 10.6118/jmm.2016.22.3.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/12/2016] [Accepted: 08/26/2016] [Indexed: 11/24/2022] Open
Abstract
Objectives This study aimed to evaluate the effects of vulvar dermatoses (VD) and vulvar infections (VE) on anxiety, depression scores, general, and dermatological quality of life (QOL) of women. Methods We conducted a cross-sectional survey on patients diagnosed with VD and VE. All patients were assessed using a sociodemographic form, Skindex-29 scale, World Health Organization QOL (WHOQOL) BREF scale, Hamilton anxiety rating scale (HAM-A), Hamilton depression rating scale (HAM-D). Results HAM-A score was significantly higher in the VD group than in the control group. Based on age groups, all subscales of Skindex-29 were found to be higher in women > 50 years. For women with severe pruritus, the symptom subscale was higher in patients with skin involvement and the function and emotion subscales were higher in patients with and emotion subscales were higher in patients with mucosal involvement. Conclusions We found that VD was particularly significantly associated with decreased QOL.
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Affiliation(s)
- Kıymet Handan Kelekçi
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - Selçuk Özyurt
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - Bülent Özkan
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - Şemsettin Karaca
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - Ali Karakuzu
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - İlgül Bilgin
- Department of Dermatology, İzmir Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
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Ozalp SS, Telli E, Yalcin OT, Oge T, Karakas N. Vulval pruritus: the experience of gynaecologists revealed by biopsy. J OBSTET GYNAECOL 2014; 35:53-6. [PMID: 25010568 DOI: 10.3109/01443615.2014.935711] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pruritus of the vulva is a common symptom among patients attending to outpatient clinics. In the present study, we aimed to assess pathologies causing vulval pruritus in the reliability of biopsy in a tertiary referral centre. A total of 137 patients undergoing vulval colposcopy because of vulval pruritus were reviewed from the hospital records retrospectively. The mean age of the patients was 47.61 ± 11.88 years and 36.5% of the patients were postmenopausal. In 101 (73.7%) of the patients, macroscopic lesions were present. In 88 (64.2%) of the patients, tolidine-positive stained areas were determined under colposcopy. In total, 68 (49.6%) of the lesions were plain, whereas 51 (37.2%) of them were depigmented. Lichen simplex chronicus, lichen sclerosis and chronic inflammation were the major pathologies associated with vulval pruritus (25.5%, n = 35; 20.4%, n = 28; 14.6%, n = 20). In conclusion, several pathologies out of vulvovaginal candidiasis may lead to vulval pruritus and clinicians should be aware of the importance of biopsy in determining the underlying pathology.
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Affiliation(s)
- S S Ozalp
- Department of Gynaecology and Obstetrics, Eskisehir Osmangazi University, School of Medicine , Eskisehir , Turkey
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