Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: A nationwide needs assessment survey

The International Society for the Study of Vulvovaginal Disease (ISSVD) Vulvar Awareness Day Campaign: Knowledge of Vulvovaginal Diseases Among Italian Obstetrics and Gynecology Residents

OBJECTIVES

The objective of this study is to investigate vulvovaginal disease (VVD) awareness in Italian obstetrics and gynecology (Ob/Gyn) residents.

MATERIALS AND METHODS

A 25-question survey on VVD basic knowledge (17 questions) and willingness to improve it (8 questions) was distributed through Ob/Gyn resident online group chats, from different Italian Universities in January 2023. A total number of 250 residents were invited to participate; 124 responses were obtained (response rate: 50%). Data were collected and analyzed using descriptive statistics through REDCap.

RESULTS

Overall, 87 of the 124 respondents (70%) fully completed the questionnaire and represented the study group. Residents were distributed among years of residency: 15% first year, 31% second year, 23% third year, 11% fourth year, and 20% fifth year. Most (60%) never attended a VVD clinic during residency, with an increasing percentage of attendance in later residency years (15% at first year vs 65% at fifth).Participants reported low knowledge of vulvar precancerous lesions and vulvoscopy but better knowledge of vaginitis, vulvar self-examination, and lichen sclerosus. Of the respondents, 50% were not satisfied with the education provided during residency, and more than 60% lacked confidence in managing VVD.All participants expressed a strong desire to improve their knowledge and skills, with 100% agreeing that every gynecologist should know the "basics" and 98% wanting to improve their knowledge through webinars (45%), lessons (34%), newsletters, and videos (19%).

CONCLUSION

Our findings indicate a significant need to improve VVD knowledge among Italian Ob/Gyn residents. Further efforts are necessary to provide information about VVD and comprehensive training programs in Italian Universities.

"Check Your Vulva"-A Patient Education and Virtual Vulva Care Pilot Project

OBJECTIVE

The aim of the study is to identify whether vulvar self-examination learned from a web site could lead to a self-identification of vulvar lesions and the feasibility of virtual vulvar care with patient submitted photos.

MATERIALS AND METHODS

The study used a prospective cohort design in a tertiary academic hospital over a 1-year period. Eligible participants who self-identified a vulvar lesion/skin changes were invited to send vulvar photos through a secure patient portal and schedule a phone consult to discuss diagnosis/management. Clinical data, photo interpretability, and patient satisfaction measures were collected. Self-referral patients versus vulva clinic waitlist patients were analyzed separately.

RESULTS

Few people were interested in submitting vulvar photos online. Twenty-eight participants directly contacted the study, 8 consented, and 6 sent in vulvar photos. Forty four of 476 on the waitlist consented but only 24 of 44 sent in photos (5% of waitlist patients). The median time for a virtual assessment was 7 days for study participants while it was 18 months for the in-person usual care pathway. Most patient submitted photos were assessable. However, 60% participants needed help from another person to take the photos. More than 90% of patients required an in-person visit for their vulvar condition/concerns. While most patients were happy with the virtual process, 58% rated their satisfaction with the ease of taking photos of the genital region as "fair" or "poor."

CONCLUSIONS

Virtual care with photos/phone calls might be feasible, although most patients are unlikely to participate. Because of patient discomfort, unease with taking photos, and patient privacy concerns, vulvar care should continue to be in-person for most new consults.

Presenting Symptoms and Diagnosis of Vulvar Lichen Sclerosus in Premenopausal Women: A Cross-Sectional Study

OBJECTIVES/PURPOSE

Presenting symptoms of vulvar lichen sclerosus (LS) specific to premenopausal women are not well reported in the literature and may differ from those in postmenopausal women. This study aimed to characterize the presentation of vulvar LS among premenopausal women.

MATERIALS AND METHODS

An observational web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, timing of diagnosis, alternate diagnoses, and presence of concomitant autoimmune conditions.

RESULTS

Of the 956 responses received, 503 met inclusion criteria of biopsy-confirmed LS and premenopausal status. Average age of symptom onset was 27 years, and average age of diagnosis was 32 years, with a 4-year delay in diagnosis. Symptoms most present were dyspareunia (68%) and tearing with intercourse or vaginal insertion (63%). Symptoms that affect the individual most were also dyspareunia (44%) and tearing with intercourse or vaginal insertion (39%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%) and tearing with intercourse or vaginal insertion (26%). Most common skin changes included hypopigmentation (81%), vulvar fissures (72%), and labial resorption (60%), with fissures affecting the individual the most (48%). Sixty-six percent of the respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Hypothyroidism was the most common concurrent autoimmune condition (10%).

CONCLUSIONS

Vulvar LS affects premenopausal women, commonly presenting with dyspareunia and tearing with intercourse. This condition should be considered and evaluated in premenopausal women presenting with vulvar symptoms and sexual pain.

Learning on the Go: Assessing Knowledge Gained From Medical Podcasts Created for Vulvovaginal Disease Education

OBJECTIVE

The aim of the study was to evaluate the effectiveness of "The Vulva Diaries" podcast as a novel learning tool for vulvovaginal disease education.

MATERIALS AND METHODS

Medical students and residents were invited to participate in the study using social media advertisements. Online pretests and posttests, one based on a podcast episode regarding genital herpes and the other on lichen sclerosus, were used to assess changes in knowledge level pre- and post-podcast listening in medical students and residents respectively. A second posttest was sent out 2 weeks after the first to assess knowledge retention. Results were analyzed using paired t tests comparing mean scores before and after podcast.

RESULTS

In medical students, the average test score increased by 20% (n = 56, p < .001). Similarly, in residents the average test score increased by 23.1% (n = 22, p < .001). Medical students and residents rated their average preference for using podcasts as compared with other resources at 3.6 and 3.7/5, respectively. Furthermore, in both groups, there was no significant difference between average scores for posttest 1 versus posttest 2 written 2 weeks later suggested excellent knowledge retention.

CONCLUSIONS

"The Vulva Diaries" podcast increases knowledge on vulvovaginal disease and is an effective learning tool for health care trainees in women's health. This study emphasizes the role of podcasts as a valuable educational resource within gynecology. The success of such initiatives will hopefully bolster the effort to correct the lack of provider knowledge in treating vulvovaginal diseases.

Equity in visual representation of vulvar conditions in major gynecology textbooks

OBJECTIVES

To evaluate images of vulvar conditions (VCs) in major gynecologic textbooks and describe the skin tone representation.

METHODS

Images of VCs in gynecological textbooks for medical students, obstetrics and gynecology (OBG) residents, and fellows were compiled. Texts were categorized into education levels (medical student, resident, or fellow) and selected based on the recommendations of OBG attendings and fellows at LSUHSCNew Orleans. Skin tones were scored according to the Fitzpatrick Scale (FS) and categorized as benign, infectious, inflammatory, and dysplasia/cancerous. Publishing and primary author demographics were collected. Proportional odds regression (POR) predicted FS based on image pathologies and book titles.

RESULTS

Of 512 images selected from 21 textbooks, 77.0% [N = 395] were lighter skin tones (FS I-III). VCs were represented by the darkest skin tone (FS of VI) in 19.6% of images in texts targeting residents, compared to 8.5% and 4.5% in fellow and student textbooks, respectively (p <0.001). Compared to a cornerstone surgical atlas, the pediatric and adolescent gynecology text consisted of lighter skin tones. A prominent general gynecology text used darker skin tones. Images of infectious conditions were more likely to be darker skin tones than other VCs (p = 0.010).

CONCLUSIONS

Most textbook images of VCs represent lighter skin tones, and women with darker skin are more underrepresented in texts geared at fellows and students. Inadequate exposure to the appearance of VCs on darker skin promotes and propagates racial inequities in healthcare. Medical textbooks should present visually diverse images of vulvar pathologies to train physicians to be well versed in caring for patients of all skin tones.

Desquamative Inflammatory Vaginitis and Plasma Cell Vulvitis Represent a Spectrum of Hemorrhagic Vestibulovaginitis

OBJECTIVE

The aim of the study was to identify whether desquamative inflammatory vaginitis (DIV) and plasma cell vulvitis (PCV) are distinct clinicopathologic entities.

MATERIALS AND METHODS

The pathology database identified biopsies described as "vaginitis" or "vulvitis" occurring in nonkeratinized epithelium or mucocutaneous junction. Exclusions were age less than 18 years, unavailable slides or records, concurrent neoplasia, or histopathology consistent with other entities. Clinical data included demographics, symptoms, examination, microbiology, treatment, and response. Histopathologic review documented site, epithelial thickness and characteristics, infiltrate, and vascular abnormalities. Cases were analyzed according to histopathologic impression of DIV or PCV based on previous pathologic descriptions.

RESULTS

There were 36 specimens classified as DIV and 18 as PCV from 51 women with mean age of 51 years; 3 (6%) had concurrent biopsies with both. Pain was more common in PCV, but rates of discharge, itch, and bleeding were comparable. Rates of petechiae or erythema were similar and vaginal examination was abnormal in 72% of PCV cases. All DIV and 33% of PCV occurred in squamous mucosa; the remaining PCV cases were from mucocutaneous junction. Mean epithelial thickness, rete ridge appearance, exocytosis, and spongiosis were similar in DIV and PCV. Epithelial erosion, wide-diameter lesions, plasma cells, and stromal hemosiderin occurred in both but were more common in PCV. Lymphocyte-obscured basal layer, narrow-diameter lesions, hemorrhage, and vascular congestion were seen in both, but more common and marked in DIV.

CONCLUSIONS

Desquamative inflammatory vaginitis and PCV have overlapping symptoms, signs, and histopathologic features. They may represent a single condition of hemorrhagic vestibulovaginitis with varying manifestations according to location and severity.

Erosive Lichen Sclerosus-A Clinicopathologic Subtype

Objective

The aim of the study was to identify whether erosive lichen sclerosus (LS) is a distinct clinicopathologic subtype.

Materials and Methods

The pathology database was searched for “erosion,” “erosive,” “ulcer,” and “lichen sclerosus.” Inclusion criteria were histopathologic diagnosis of LS and erosion or ulcer overlying a band of hyalinization and/or fibrosis. Exclusions were concurrent neoplasia and insufficient tissue. Histopathologic review documented site, epithelial thickness, adjacent epidermal characteristics, infiltrate, and dermal collagen abnormality. Clinical data included demographics, comorbidities, examination findings, microbiologic results, treatment, and response.

Results

Ten examples of erosive LS and 15 of ulcerated LS occurred in 24 women with a mean age of 67 years. Ulcerated LS was associated with diabetes and nontreatment at time of biopsy. Clinicians identified red patches in all but 1 case of erosive LS. Ulcerated LS was documented as fissure, ulcer, or white plaque, with 8 (53%) described as lichenified LS with epidermal breaches. Erosive LS favored hairless skin with normal adjacent stratum corneum sloping gently into erosion, whereas most ulcers in LS had an abrupt slope from hair-bearing skin. All cases were treated with topical steroids; 2 patients with erosive LS and 10 with ulcerated LS also had oral antifungals, topical estrogen, antibiotics, and/or lesional excision. Treatment yielded complete resolution in 50%.

Conclusions

Erosive LS is an unusual clinicopathologic subtype characterized by red patches on hairless skin seen microscopically as eroded epithelium overlying a band of hyalinized or fibrotic collagen. In contrast, ulcerated LS is usually a traumatic secondary effect in an uncontrolled dermatosis.