Coital pain in the elderly: could a low dose estriol gel thrill the vulvar vestibule?

Evaluation of polygenic risk scores for hormones and receptors levels in patients with vestibulodynia: a case-control study

BACKGROUND

Vulvodynia is a multifactorial disease affecting 7%-16% of reproductive-aged women in general population; however, little is still known about the genetics underlying this complex disease.

AIM

To compare polygenic risk scores for hormones and receptors levels in a case-control study to investigate their role in vulvodynia and their correlation with clinical phenotypes.

METHODS

Our case-control study included patients with vestibulodynia (VBD) and healthy women. All participants underwent a vestibular cotton swab test and the assessment of their: pelvic floor, vestibular trophism, ultrasound vestibular mucosa thickness, and current perception threshold levels (Neurometer CPT device). Shallow whole genome sequencing and polygenic risk score calculations were performed. Linear regression models were applied to predict whether genomic predisposition varied significantly between cases and controls, and to investigate the relationship of polygenic risk scores with clinical endophenotypes.

OUTCOMES

The genomic predisposition to hormones and receptors levels, together with clinical endophenotypes, can support VBD diagnosis and personalized treatment of related pain condition.

RESULTS

Thirty women with VBD and 30 controls were recruited. Significant differences between cases and controls were observed for body mass index, vestibular mucosa thickness, vestibular trophic health, pelvic floor hypertone and pain sensitivity (P < .05). Cases showed a genomic predisposition to higher levels of membrane-associated progesterone receptor component 1 compared to controls (P < .05). When considering the clinical endophenotypes, cases showed significant correlations between their polygenic risk scores with several clinical measures: predicted genomic levels of testosterone and estrogen receptor and the vestibular mucosa thickness values (estimates: 9.74E-09 and 9.16E-08, respectively; P < .05); predicted genomic levels of prolactin and Neurometer data at 250 Hz (-2.15E-07; P < .05); predicted genomic levels of prolactin, membrane-associated progesterone receptor component 2 and mineralocorticoid receptor and Neurometer data at 5 Hz (-3.75E-07, -3.43E-07 and -3.06E-07, respectively; P < .05).

CLINICAL IMPLICATIONS

Introduction of polygenic risk scores evaluation in clinical practice can assist early diagnosis and personalized therapeutic treatment of VBD.

STRENGTHS AND LIMITATIONS

Polygenic risk scores and clinical data allowed the identification of disease endophenotypes and highlighted the possibility of a personalized therapeutic approach. As limitations, these data should be confirmed on a larger cohort and polygenic risk score calculation should be adapted to ancestries other than European.

CONCLUSION

Cases showed significant differences compared to controls on both clinical and genetic data and specific endophenotypes necessary to classify disease development and treatment were identified.

Insights into the vulvar component of the genitourinary syndrome of menopause (GSM)

Genitourinary syndrome of menopause is a comprehensive term that groups genital, urinary and sexual signs and symptoms mainly due sex hormone deficiency and aging, with a crucial impact on quality of life of midlife women. While this broad definition captures the common underlying physiopathology and the frequent overlap of symptomatology, improving knowledge about different components of genitourinary syndrome of menopause may be relevant for individualized treatment, with possible implications for efficacy, compliance and satisfaction. This narrative review focuses on the vulvar component of genitourinary syndrome of menopause, highlighting anatomical and functional peculiarities of the vulva that are responsible for some of the self-reported symptoms, as well as specific signs at physical examination. Increasing evidence points towards a pivotal role of vulvar vestibular health in the occurrence of sexual pain, one of the most common and distressing symptoms of genitourinary syndrome of menopause, which should be evaluated with validated scales taking a biopsychosocial perspective. This is an essential step in the recognition of different phenotypes of genitourinary syndrome of menopause and in the assessment of the most effective diagnostic and therapeutic algorithm. Menopausal vulvar health deserves more research into tailored non-hormonal and hormonal treatment options.

Effectiveness of Combination of Tibolone and Lactobacilli Plus Lactoferrin in Postmenopausal Women with Vulvar Vestibular Pain: A Preliminary Report

BACKGROUND

Postmenopausal dyspareunia and vulvar pain are common complaints, affecting about 60% of women within a few years after hormone levels begin to decline (such as estrogen and androgen). Atrophic changes mainly located in the vulvar vestibule and vulnerability to vulvovaginal infections in postmenopause could be predisposing factors to the development of vulvar burning/pain and introital dyspareunia (vestibulodynia secondary to atrophy). Tibolone is the most effective and safe alternative for treating menopausal symptoms. The role of Lactobacilli and lactoferrin shows its effectiveness in the treatment of vaginal microbiota dysbiosis. The aim of the present study was to assess the efficacy of the combination of tibolone and an oral-specific Lactobacilli mixture in combination with bovine lactoferrin as synergistic therapy for the treatment of vestibulodynia related to atrophy.

METHODS

In this study, we included 35 postmenopausal women with at least 1 year of amenorrhea, affected by vulvar burning/pain and introital dyspareunia. All participants received treatment with open-label, oral Tibolone 2.5 mg and Lactobacilli mixture (5 × 109 CFU per capsule) in combination with bovine lactoferrin (Respecta®). Each product was taken once daily for 90 days.

RESULTS

After 90 d of therapy with TIB+ Respecta®, in 30 women that completed the treatment, there was a statistically significant decrease from the baseline in the mean of the Visual Analog Scale for vulvar burning/pain and a reduction in scores in the pain evaluation test.

CONCLUSIONS

This study provides evidence that the combination of TIB+ Respecta® was effective in reducing symptoms related to vestibular pain and hypersensitivity in a postmenopausal setting.

Topical estrogens for the treatment of superficial dyspareunia related to genitourinary syndrome of menopause in women with a history of endometriosis: A clinical dilemma

Estrogen withdrawal, which occurs with the cessation of ovulation, causes genitourinary syndrome of menopause in up to 50-85% of women. Symptoms may profoundly impact quality of life and sexual function, interfering with enjoyment of sex in up to three out of four individuals. Topical estrogens have been found to provide symptom relief with minimal systemic absorption and appear to be superior to systemic therapy as what regards genitourinary symptoms. However, conclusive data on their appropriateness in postmenopausal women with a history of endometriosis is not available and the hypothesis that exogenous estrogen stimulation may reactivate endometriotic foci or even promote their malignant transformation is still open. On the other hand, endometriosis affects around 10% of premenopausal women, many of which may be exposed to an acute hypoestrogenic depletion even before spontaneous menopause occurs. This considered, excluding on principle patients with a history of endometriosis from first-line treatment for vulvovaginal atrophy would mean excluding a considerable percentage of the population from adequate care. More robust evidence is urgently needed in these regards. Meanwhile, it would appear reasonable to tailor the prescription of topical hormones in these patients, taking into account the entity of symptoms and the impact such symptoms have on patients' quality of life, as well as the form of endometriosis and the possible risks hormonal may entail. Moreover, the application of estrogens on the vulva instead of the vagina could be efficacious, while outweighing the possible biological cost of hormonal treatment in women with a history of endometriosis.

Effectiveness of Two Transcutaneous Electrical Nerve Stimulation (TENS) Protocols in Women with Provoked Vestibulodynia: A Randomized Controlled Trial

BACKGROUND

Vestibulodynia (VBD) is the most common form of vulvodynia. Because VBD is a pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as treatment. This study aims to evaluate the effects of two-parameter combinations (frequency and pulse duration) of TENS in reducing pain intensity and dyspareunia in VBD.

METHODS

A randomized, double-blind, controlled trial was conducted to study the effect of two different electrical stimulation treatment regimens on women with VBD receiving domiciliary TENS. Outcomes were the mean change from baseline at 60 and 120 days of burning/pain and dyspareunia (VAS), Vulvar Pain Functional Questionnaire (V-Q), Female Sexual Functioning Index (FSFI) and vaginal electromyography measurements.

RESULTS

A total of 78 subjects, 39 in each group, completed the trial. Patients in Groups 1 and 2 received a mean of 46.9 and 48.4 TENS sessions. By day 120, there was a 38.2% reduction in the burning/pain and a 52.1% reduction in the dyspareunia VAS scores in Group 1, as compared to 21.3% (p = 0.003) and 23.1% in Group 2 (p = 0.01), respectively. FSFI, V-Q, and muscle-strength measures also improved but were not statistically significant.

CONCLUSIONS

Our findings showed the potential of TENS in the treatment of VBD.

Treating where it hurts-a randomized comparative trial of vestibule estradiol for postmenopausal dyspareunia

OBJECTIVE

To compare efficacies of two strengths of estradiol cream applied to the vulvar vestibule and use of silicone lubricant to reduce intercourse pain scores in postmenopausal women with moderate/severe dyspareunia.

METHODS

This pilot randomized comparative trial assigned 50 women to nightly applications of estradiol cream, 50 or 100 μg, for 12 weeks. We asked women to have lubricated penetration twice weekly, with intercourse or performing a tampon test. Pain, recorded in dairies, was rated using the 0-10 Numerical Rating Scale. We assessed biopsychosocial outcomes, urinary symptoms, and measured serum estradiol levels and endometrial stripe thicknesses. We performed physical examinations to determine tenderness levels of the vestibule, vagina, pelvic floor muscles, bladder, uterus, and adnexa. Comparisons were made using two-sample t test, Wilcoxon rank-sum test, or χ2 /Fisher's exact test.

RESULTS

Forty-seven women (94%), with a mean age of 59.7 years, completed the trial. The baseline median intercourse pain score was 8/10 (interquartile range, 6, 8). After 12 weeks, we measured no statistically significant difference between groups in the primary outcome, intercourse pain score, or any secondary outcome measure. For both groups together, the median intercourse pain score diminished by 50% after 4 weeks and 75% after 12 weeks ( P < 0.001). The most tender anatomic area, the vulvar vestibule, improved by 82% to 100% ( P < 0.001) with therapy. We did not measure a statistically significant difference in serum estradiol levels or endometrial stripe thickness between groups.

CONCLUSION

Estradiol cream applied to the vulvar vestibule, paired with precoital silicone lubricant, is a promising alternative to vaginal therapy for dyspareunia.

Where does postmenopausal dyspareunia hurt? A cross-sectional report

OBJECTIVE

A common symptom of genitourinary syndrome of menopause (GSM) is dyspareunia, attributed to vulvovaginal atrophy. Our objective was to systematically describe the pain characteristics and anatomic locations of tenderness in a cohort with moderate/severe dyspareunia likely due to GSM.

METHODS

This cross-sectional study reports the baseline data of postmenopausal women with dyspareunia screened for an intervention trial of topical estrogen. Postmenopausal women not using hormone therapy who had moderate or severe dyspareunia were eligible if estrogen was not contraindicated. Biopsychosocial assessments were performed using the Vulvar Pain Assessment Questionnaire, and participants underwent a systematic vulvovaginal examination that included a visual assessment and cotton swab testing for tenderness rated using the Numerical Rating Scale (0-10). Vaginal pH and mucosal sensitivity were assessed; pelvic floor muscles and pelvic viscera were palpated for tenderness.

RESULTS

Fifty-five eligible women were examined between July 2017 and August 2019. Mean age was 59.5 ± 6.8 years, and duration of dyspareunia was 6.2 ± 4.3 years. The mean intercourse pain score was 7.3 ± 1.8, most often described as "burning" and "raw." Ninety-eight percent had physical findings of vulvovaginal atrophy. Median pain scores from swab touch at the vulvar vestibule (just outside the hymen) were 4 to 5/10, and topical lidocaine extinguished pain. Median vaginal mucosal pain was zero.

CONCLUSIONS

Participants described their pain as "burning" and "dry." Tenderness was most severe and most consistently located at the vulvar vestibule. Correlating the symptom of dyspareunia with genital examination findings may further our understanding of treatment outcomes for GSM.

Real-World Practices and Attitudes Towards Intimate Self- Care: Results From An International Women's Survey

OBJECTIVE

Vulvovaginal health is important to women's overall health, fertility, sexuality, self-perception, self-confidence and intimacy. It is important to identify the existing perceptions and levels of knowledge about intimate care practices from women in different countries, and with different cultures, religions, and perspectives to help women overcome barriers to optimal intimate care.

METHODS

An anonymous online survey about general and intimate hygiene routines/habits was distributed across 10 countries (England, France, Germany, Italy, Portugal, Russia, China, Philippines, Taiwan, Thailand). The sample consisted of around 10,000 women (aged 18 to 60 years) recruited through an online panel.

RESULTS

The survey indicates that for many women, cleaning the intimate area is not just about hygiene, but also about taking care of themselves. Intimate care practices, performed daily, varies widely among the countries (from 38% to 91%). Italy, Philippines Portugal, Russia and Thailand were the countries with higher percentage. Intimate care is mainly associated with hygiene and health benefit, but interestingly women engage in intimate care more often with age. Most women worldwide are comfortable talking about female genitalia but still consider it a taboo topic, particularly among younger generations. Asian countries continue to carry negative connotations.

CONCLUSIONS

This survey is the first of its kind for number of women involved in this research and for multi-cultural design. Women perceive that practicing intimate care positively impacts their health and wellbeing. However, intimate care is still not one of the most frequent daily routines for many women.

Vestibular Mucosa Thickness Measured by Ultrasound in Patients Affected by Vestibulodynia: A Case-Control Study

Introduction

A multifactorial etiology has been implicated in the development and maintenance of vestibulodynia (VBD), and atrophic changes of the vestibular mucosa have been observed in many patients.

Aim

To assess the vestibular mucosa thickness in patients with VBD by comparing this sample with a control group of healthy fertile women and postmenopausal patients with symptoms of genitourinary syndrome of menopause (GSM).

Methods

Vestibular mucosa thickness was measured with a 20 MHz ultrasound probe (DermaScan C, Cortex Technology, Denmark), including both the epidermis and dermis.

Main outcome measures

All women were evaluated by anamnesis, physical examination, and self-report symptoms. Thickness of the vestibular mucosa (expressed in micrometers) was determined by the B-mode, excluding the hyperechogenic entrance echo and hypoechogenic subcutis. Clinical data related to VBD and GSM were recorded using a 0- to 10-point visual analog scale related to dyspareunia and vulvar pain/burning (0 = no pain; 10 = worst possible pain).

Results

A total of 85 patients were recruited: 24 with VBD, 20 with GSM-related symptoms, and 20 matched controls. Vestibular mucosa thickness measurements were not significantly different between the VBD (mean ± DS: 1,092.5 ± 226.1 μm) and GSM groups (1,059.7 ± 221.5 μm), while the parameter was significantly lower (P < .01) than the control group (1,310.6 ± 250.0 μm). Correlation analysis in the VBD and GSM groups between low vestibular mucosa thickness and symptom intensity (burning/pain and dyspareunia) showed a significant correlation.

Conclusion

Patients with VBD have a vestibular mucosa with a lower thickness than healthy women of the same age, with an almost identical value to that found in postmenopausal women. Furthermore, a low vestibular mucosa thickness in the VBD and GSM groups showed a significant correlation with burning/pain intensity and dyspareunia severity.

F Murina, S Barbieri, C Lubrano, MD, et al. Vestibular Mucosa Thickness Measured by Ultrasound in Patients Affected by Vestibulodynia: A Case-Control Study. Sex Med 2021;9:100320.

Efficacy and safety of a novel vaginal medical device in recurrent bacterial vaginosis: a multicenter clinical trial

BACKGROUND

The effectiveness of a new vaginal medical device, which contains polycarbophil, 0.04% lauryl glucoside and glycerides (Polybactum^®, Effik Italia Spa, Cinisello Balsamo, Milan, Italy), in reducing BV recurrence rate was investigated.

METHODS

This was a multicenter, open label, not comparative study. Women over 18 years old affected by recurrent BV were included. The latest episode was diagnosed by Amsel criteria 6-9 days before the start of the study and treated with vaginal metronidazole (gel 0.75% mg for 5 days or ovules 500 mg for 7 days). The recurrence was defined by at least 2 episodes in the previous 12 months. Polybactum^® vaginal ovules, day 1-4-7, were started within the 12^th and the 24^th hour after the end of metronidazole therapy and repeated monthly for 3 cycles.

RESULTS

The first 41 patients enrolled were evaluated for an interim analysis 6 months after the study started; 2 patients interrupted the trial, leaving 39 evaluable subjects. The recurrence rate was significantly reduced compared to previous published data (10.26% vs. 40% P<0.001). In 35 patients without recurrence, the assessment of Lactobacillus vaginal flora performed by phase contrast microscopy evidenced a significant improvement form baseline (P=0.022) The investigator global assessment of tolerability was excellent in 38 out of 39 cases.

CONCLUSIONS

Our research showed that 3 monthly cycles of Polybactum^® ovules administered after one course of metronidazole vaginal therapy can reduce the rate of Bacterial vaginosis recurrence and improve the vaginal milieu, favoring the growth of vaginal lactobacillus species.

Efficacy of an orally administered combination of Lactobacillus paracasei LC11, cranberry and D-mannose for the prevention of uncomplicated, recurrent urinary tract infections in women

BACKGROUND

Most women experience a urinary tract infection (UTI) at least once in their lifetime. The present study determined the efficacy and safety of a combination of Lactobacillus paracasei LC11, cranberry and D-mannose (Lactoflorene Cist^®) in the prophylaxis of recurrent uncomplicated UTIs in premenopausal women.

METHODS

This single-centre study enrolled premenopausal women aged 18-50 years with an acute UTI and a history of recurrent uncomplicated UTIs. Patients were first treated with fosfomycin (3 g once a day for 2 days) to eliminate any underlying infection, followed by treatment with Lactoflorene Cist^® once a day for 10 days/month for 90 days (Group 1), Lactoflorene Cist^® once daily for 90 days (Group 2) or no treatment (Group 3; control). The main study endpoint was the rate of UTI recurrence during the study period. Any adverse events with treatment were also recorded.

RESULTS

A total of 55 women (mean age 39.3 years; range: 20-46) were enrolled in the study. A significantly higher proportion of patients in the control group experienced UTIs during the study period compared with the two treatment groups (52.9% vs 16.0% in Group 1 and 15.5% in group 2; p < 0.01). Similarly, a higher proportion of patients in Group 1 (65.8%) and Group 2 (68.7%) remained UTI-free during the study versus the control group. No adverse events were reported in the treated patients.

CONCLUSION

Prophylactic treatment with Lactoflorene Cist^® was effective and safe in the management of recurrent uncomplicated UTIs in premenopausal women.

Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function

The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.

Microablative fractional CO2 laser for the genitourinary syndrome of menopause: power of 30 or 40 W?

This retrospective case-control study aimed to compare 30 versus 40 W power of CO₂ laser for the therapy of genitourinary syndrome of menopause (GSM). Postmenopausal women with severe intensity of dyspareunia and dryness were eligible to be included in this study. Primary outcomes were dyspareunia and dryness. Secondary outcomes were itching/burning, dysuria, frequency and urgency, Female Sexual Function Index (FSFI), vaginal maturation value (VMV), and Vaginal Health Index Score (VHIS). One laser therapy was applied every month for 3 months. Outcomes were evaluated at baseline and 1 month following the 3rd therapy. Fifty (25 per group) women were included in this study. In the 30-W group, mean improvement of dyspareunia, dryness, itching/burning, FSFI, VMV, and VHIS was 6.1 ± 1.7, 6.0 ± 1.9, 5.9 ± 2.0, 16.6 ± 6.7, 29.9 ± 13.0, and 11.0 ± 2.9, respectively (within group comparisons all p < 0.001). In the 40-W group, mean improvement of dyspareunia, dryness, itching/burning, FSFI, VMV, and VHIS was 6.1 ± 1.7, 6.5 ± 2.0, 5.2 ± 2.5, 14.8 ± 7.1, 25.0 ± 13.4, and 10.5 ± 4.1, respectively (within-group comparisons, all p ≤ 0.001). Comparison between 30 and 40 W revealed that mean improvement or presence of all GSM symptoms and clinical signs was not statistically significant different. CO₂ laser therapy may improve GSM symptoms and clinical signs. This improvement did not seem to associate to power of 30 or 40 W.