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Saçıntı KG, Razeghian H, Bornstein J. Surgical Treatment for Provoked Vulvodynia: A Systematic Review. J Low Genit Tract Dis 2024:00128360-990000000-00132. [PMID: 39105455 DOI: 10.1097/lgt.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
OBJECTIVE Provoked vulvodynia (PV), characterized by vulvar pain upon touch or pressure, is the leading cause of pain during sexual intercourse. It causes a significant decline in overall quality of life, including sexual dysfunction and mental distress. Surgical interventions, such as perineoplasty and vestibulectomy, are considered a last resort for PV cases unresponsive to less invasive therapies. This systematic review evaluates the efficacy of surgery for PV and suggests areas for future research. MATERIALS AND METHODS The literature search encompassed PubMed, Scopus, Web of Science, and Cochrane Library, identifying relevant peer-reviewed studies up to August 21, 2023. RESULTS Out of 1102 records retrieved, 29 met the eligibility criteria. Surgery was typically considered after failed conservative treatments. In 15 of the 29 studies defining surgical success as a significant reduction in dyspareunia, success rates ranged from 52% to 93%. Six studies using validated scales for pain assessment noted a significant reduction in vulvar pain following surgery (p < .001). Two studies reported enhancements in sexual function ranging from 57% to 87%, while 3 studies found 89%-97% of women regained the ability to engage in sexual intercourse after surgery. Patient satisfaction rates ranged from 79% to 93%. Bartholin cysts occurred in up to 9% of cases, the most common complication reported. CONCLUSION Surgery seems to be an effective and safe PV treatment option with success rates ranging from 52% to 97%, depending on the variation of outcome measures. Randomized clinical trials with established outcome measures are needed to determine the best surgical approach with minimal operative risk and optimal long-term outcomes.
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Affiliation(s)
| | - Hosna Razeghian
- Luigi Vanvitelli University of Campania School of Medicine and Surgery, Naples, Italy
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Jackman VA, Bajzak K, Rains A, Swab M, Miller ME, Logan GS, Gustafson DL. Physical Modalities for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023. Int J Womens Health 2024; 16:769-781. [PMID: 38737495 PMCID: PMC11086396 DOI: 10.2147/ijwh.s445167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/25/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Localized provoked vulvodynia (LPV) is a prevalent sexual health condition with significant negative impacts on quality of life. There is a lack of consensus regarding effective management. Methods We used Arksey and O'Malley's five-step method to identify, collate, and evaluate literature published between 2010 and 2023. The scoping review investigated the efficacy or effectiveness of interventions in the management of LPV. The aim of this paper is to map the literature on the efficacy or effectiveness of physical interventions. Results The review produced 19 primary studies of physical interventions for LPV. These include acupuncture, laser therapy, physiotherapy, transcutaneous electrical nerve stimulation, low-intensity shockwave therapy, transcranial direct current stimulation, and vestibulectomy. Conclusion Published studies that investigated a range of physical treatments for LPV showed some positive effects, except for transcranial direct-current stimulation. The remaining modalities demonstrated improved sexual pain and treatment satisfaction, when measured. Findings were mixed for non-sexual pain. There was insufficient evidence to draw conclusions regarding other outcomes. Researchers are encouraged to conduct larger, high-quality studies that sample more diverse patient populations and use patient-oriented outcomes to assess effectiveness of physical modalities.
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Affiliation(s)
- Victoria A Jackman
- Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John’sCanada
| | - Krisztina Bajzak
- Discipline of Obstetrics and Gynecology, Memorial University, Newfoundland & Labrador, St. John’sCanada
| | - Alex Rains
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michelle Swab
- Health Sciences Library, Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John’sCanada
| | - Michelle E Miller
- Discipline of Obstetrics and Gynecology, Memorial University, Newfoundland & Labrador, St. John’sCanada
| | - Gabrielle S Logan
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Diana L Gustafson
- Division of Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John’sCanada
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Penteado SRL, Bonduki CE, de Araújo TRE, Alves SV, de Luccas Batista NMT, Ambrogini CC, Sartori MGF. Individualized multidisciplinary therapy for vulvodynia. J Obstet Gynaecol Res 2024; 50:147-174. [PMID: 37968775 DOI: 10.1111/jog.15829] [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: 08/15/2023] [Accepted: 11/04/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE The main objective of this review was to develop strategies for individualizing multidisciplinary therapy for vulvodynia. METHODS We conducted two literature searches; the first one focused on clinical trials assessing vulvodynia treatments published after the recommendations of the expert committee of the Fourth International Consultation on Sexual Medicine. The second search targeted studies identifying predictive factors and mediators of vulvodynia treatments, published from the earliest date to October 2022. RESULTS Based on data from 55 relevant studies, we developed models of individualized multidisciplinary therapy targeting groups of women less responsive to multidisciplinary therapy (characterized by women with higher vulvar pain intensity, impaired sexual functioning, and vulvodynia secondary subtype) and to physical therapy, as an isolated treatment (characterized by women with increased pelvic floor muscle tone and vulvodynia primary subtype). Each individualized multidisciplinary therapy model comprises three components: psychotherapy, medical care, and physical therapy. These components provide distinct therapeutic modalities for distinct subgroups of women with vulvodynia; the women subgroups were identified according to the characteristics of women, the disease, partners, and relationships. Additionally, for women with provoked vestibulodynia who exhibit less benefits from vestibulectomy (such as those with higher levels of erotophobia, greater vulvar pain intensity, and the primary subtype) and encounter resistance to individualized multidisciplinary therapy, we suggest additional conservative treatments before performing vestibulectomy. CONCLUSION Our study is a pioneer in the development of models that allow the individualization of multidisciplinary therapy for vulvodynia and represents a significant advance in the clinical practice of gynecologists, physiotherapists, and psychologists.
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Affiliation(s)
| | - Claudio Emilio Bonduki
- Department of Gynecology, Federal University of São Paulo-UNIFESP, São Paulo, São Paulo, Brazil
| | | | - Suzana Valeska Alves
- Department of Gynecology, Federal University of São Paulo-UNIFESP, São Paulo, São Paulo, Brazil
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Santangelo G, Ruggiero G, Murina F, Di Donato V, Perniola G, Palaia I, Fischetti M, Casorelli A, Giannini A, Di Dio C, Muzii L, Benedetti Panici P, Bogani G. Vulvodynia: A practical guide in treatment strategies. Int J Gynaecol Obstet 2023; 163:510-520. [PMID: 37154479 DOI: 10.1002/ijgo.14815] [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: 12/16/2022] [Revised: 03/20/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
Vulvodynia is a debilitating condition characterized by chronic vulvar pain, with a detrimental impact on the patient's overall quality of life. Its etiology is multifactorial, but still in the process of being clearly outlined. Vulvodynia is not a single entity. It is a heterogeneous condition characterized by multiple triggers, making it challenging to define a reference standard for its treatment. In this manuscript we selected all articles including the following key criteria: "vulvodynia". The primary outcomes observed included the resolution of chronic pelvic pain, dyspareunia and sexual satisfaction, psychological well-being, and overall quality of life. Most pharmacologic treatments require further evidence to be recommended. On the other hand, non-pharmacologic approaches such as psychotherapy, physical therapy, and surgery have received stronger support. This review summarizes pros and cons of adopting available treatments. Multimodal approaches should be introduced to improve patient outcomes. Further investigations are warranted to improve patients' quality of life.
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Affiliation(s)
- Giusi Santangelo
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Gianfilippo Ruggiero
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Filippo Murina
- Lower Genital Tract Disease Unit, Obstetrics and Gynecology Department, V. Buzzi Hospital, University of Milan, Milan, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giorgia Perniola
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Innocenza Palaia
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Margherita Fischetti
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Assunta Casorelli
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Camilla Di Dio
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giorgio Bogani
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Bohm-Starke N, Ramsay KW, Lytsy P, Nordgren B, Sjöberg I, Moberg K, Flink I. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2022; 19:789-808. [PMID: 35331660 DOI: 10.1016/j.jsxm.2022.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/01/2022] [Accepted: 02/08/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences and there is a need for systematically summarizing the controlled trials in this field. AIM To provide an overview of randomized controlled trials and non-randomized studies of intervention for PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines. DATA SOURCES The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021. STUDY ELIGIBILITY CRITERIA Population: Premenopausal women with PVD. INTERVENTIONS Pharmacological, surgical, psychosocial and physiotherapy, either alone or as combined/team-based interventions. CONTROL No treatment, waiting-list, placebo or other defined treatment. OUTCOMES Pain during intercourse, pain upon pressure or touch of the vaginal opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications. STUDY DESIGN Randomized controlled trials and non-randomized studies of interventions with a control group. STUDY APPRAISAL AND SYNTHESIS METHODS 2 reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias using established tools. The results from each intervention were summarized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development, and evaluation (GRADE). RESULTS Most results of the evaluated studies in this systematic review were found to have very low certainty of evidence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal physiotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome measures, which underlines the need to establish joint core outcome sets. CLINICAL IMPLICATIONS Our result underscores the need of stringent trials and defined core outcome sets for PVD. STRENGTH AND LIMITATIONS Standard procedures for systematic reviews and the Population Intervention Comparison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number of studies which might have resulted in a loss of important information. CONCLUSION This systematic review underlines the need for more methodologically stringent trials on interventions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2022;19:789-808.
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Affiliation(s)
- Nina Bohm-Starke
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.
| | - Karin Wilbe Ramsay
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Per Lytsy
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Birgitta Nordgren
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Women´s Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Solna, Sweden
| | - Inga Sjöberg
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Klas Moberg
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Ida Flink
- Center for Health and Medical Psychology, School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
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van der Meijden WI, Boffa MJ, Ter Harmsel B, Kirtschig G, Lewis F, Moyal-Barracco M, Tiplica GS, Sherrard J. 2021 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2022; 36:952-972. [PMID: 35411963 DOI: 10.1111/jdv.18102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/14/2022] [Indexed: 12/27/2022]
Affiliation(s)
- W I van der Meijden
- Department of Dermatology, Betsi Cadwaladr University Health Board, Bangor, UK
| | - M J Boffa
- Department of Dermatology, Mater Dei Hospital, Msida, Malta
| | - B Ter Harmsel
- Department of Gynaecology, Roosevelt kliniek, Leiden, The Netherlands
| | - G Kirtschig
- Gesundheitszentrum Frauenfeld, Frauenfeld, Switzerland
| | - F Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
| | - M Moyal-Barracco
- Department of Dermatology, Tarnier-Cochin Hospital, Paris, France
| | - G-S Tiplica
- Dermatology 2, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - J Sherrard
- Department of Sexual Health, Wycombe General Hospital, Bucks, UK
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Weinschenk S, Benrath J, Kessler E, Strowitzki T, Feisst M. Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study. Sex Med 2022; 10:100482. [PMID: 35063914 PMCID: PMC9023246 DOI: 10.1016/j.esxm.2021.100482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/05/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Vulvodynia (chronic vulvar pain) is a sexually debilitating disorder with a prevalence of ∼10%. Aim To investigate the effectiveness of therapy with local anesthetics (TLA) in women with severe vulvodynia, we conducted a prospective, non-controlled observational study. Methods 45 patients with severe chronic vulvodynia (primary and secondary vulvodynia, 0–10 numeric analogue scale (NAS) ≥6, median 7.9, duration ≥6 months, median 65.2 months) in an outpatient practice in Germany were treated with TLA in 3–12 sessions using procaine 1% as local anesthetic. Effectiveness was analyzed with Wilcoxon signed rank tests and Wilcoxon rank sum tests. Outcomes Therapeutic success as a reduction of pain to ≤4 NAS lasting for ≥6 months after end of therapy. Results TLA successfully reduced vulvodynia in 36 of 45 patients (80 %, responders). The NAS reduction was from 7.9 to 2.4 (P < .001). Even patients denominated as non-responders experienced a significant reduction in NAS (P = .03). In responders, long-term success was observed for 6.8–125 months (median 24.1 months). No adverse events occurred. Clinical Translation A promising new treatment for a hard-to-treat chronic female pain disorder. Strengths and Limitations Limitation: Monocentric, non-controlled observational design; Strength: the high number of patients treated. Conclusion The high success rate of TLA in this investigation offers new perspectives on the etiology of vulvodynia as a complex pain syndrome affecting several nerves of the pelvic floor, and also provides early insight into the effectiveness of TLA in women with vulvodynia. Weinschenk S, Benrath J, Kessler E, et al. Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study. Sex Med 2022;10:100482.
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Affiliation(s)
- Stefan Weinschenk
- Outpatient practice Weinschenk & Scherer, Karlsruhe, Germany; Deprtment of Gynecological Endocrinology and Fertility Disorders, Women's Hospital, Heidelberg University, Germany; the Heidelberg University Neural Therapy Education and Research (HUNTER) Group (www.hunter-heidelberg.com.
| | - Justus Benrath
- Clinic of Anesthesiology and Intensive Care, Pain Centre, University Clinic, Mannheim, Germany; the Heidelberg University Neural Therapy Education and Research (HUNTER) Group (www.hunter-heidelberg.com
| | | | - Thomas Strowitzki
- Deprtment of Gynecological Endocrinology and Fertility Disorders, Women's Hospital, Heidelberg University, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics; Heidelberg University, Heidelberg, Germany; the Heidelberg University Neural Therapy Education and Research (HUNTER) Group (www.hunter-heidelberg.com
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Vieira-Baptista P, Lima-Silva J, Preti M, Xavier J, Vendeira P, Stockdale CK. G-spot: Fact or Fiction?: A Systematic Review. Sex Med 2021; 9:100435. [PMID: 34509752 PMCID: PMC8498956 DOI: 10.1016/j.esxm.2021.100435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/07/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction The G-spot, a putative erogenous area in the anterior vaginal wall, is a widely accepted concept in the mainstream media, but controversial in medical literature. Aim Review of the scientific data concerning the existence, location, and size of the G-spot. Methods Search on Pubmed, Pubmed Central, Cochrane, clinicaltrials.gov and Google Scholar from inception to November 2020 of studies on G-spot's existence, location and nature. Surveys, clinical, physiological, imaging, histological and anatomic studies were included. Main Outcome Measure Existence, location, and nature of the G-spot. Results In total, 31 eligible studies were identified: 6 surveys, 5 clinical, 1 neurophysiological, 9 imaging, 8 histological/anatomical, and 2 combined clinical and histological. Most women (62.9%) reported having a G-spot and it was identified in most clinical studies (55.4% of women); in 2 studies it was not identified in any women. Imaging studies had contradictory results in terms of its existence and nature. Some showed a descending of the anterior vaginal wall, that led to the concept of clitourethrovaginal complex. In anatomic studies, one author could systematically identify the G-spot, while another group did not find it. Studies on innervation of the vaginal walls did not systematically identify an area with richer innervation. Conclusion The different studies did systematically agree on the existence of the G-spot. Among the studies in which it was considered to exist, there was no agreement on its location, size, or nature. The existence of this structure remains unproved. Vieira-Baptista P, Lima-Silva J, Preti M, et al. G-spot: Fact or Fiction?: A Systematic Review. Sex Med 2021;9:100435.
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Affiliation(s)
- Pedro Vieira-Baptista
- Hospital Lusíadas Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal; LAP, a Unilabs Company, Porto, Portugal.
| | - Joana Lima-Silva
- Hospital Lusíadas Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Mario Preti
- Department of Surgical Sciences University of Torino, Torino, Italy
| | - Joana Xavier
- Gynecology Department, Centro Hospitalar de São João, Porto, Portugal
| | - Pedro Vendeira
- Urology Department, Saúde Atlântica - Clínica do Dragão, Porto, Portugal
| | - Colleen K Stockdale
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Jahshan-Doukhy O, Bornstein J. Long-Term Efficacy of Physical Therapy for Localized Provoked Vulvodynia. Int J Womens Health 2021; 13:161-168. [PMID: 33603495 PMCID: PMC7882794 DOI: 10.2147/ijwh.s297389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/23/2021] [Indexed: 01/23/2023] Open
Abstract
Purpose The origin of provoked vulvodynia (PV), the main cause of entry dyspareunia, remains unclear, and the treatment is empiric. In this study, we aimed to investigate the long-term effects of physical therapy on PV in subjects using questionnaire concerning PV symptoms immediately after physical therapy and at least 10 years later. Patients and Methods This study included a total of 24 women diagnosed with PV and referred by their primary physicians to Maccabi Physical Therapy Clinic for pelvic floor rehabilitation between 2004 and 2008. Criteria such as pain relief, sexual functioning, and treatment satisfaction were assessed. Results The average pain scores of the 24 participants reduced significantly after therapy, and 42% had no pain between treatment and the time of survey. Eighty-three percent did not undergo additional treatment after the initial physical therapy and reported high or very extremely high levels of pain reduction following treatment. Multiple regression analysis found that onset type of PV and age were not associated with the treatment outcome (p = 1.0). Conclusion Physical therapy is an effective long-term treatment for primary or secondary PV, resulting in pain reduction and improved sexual function.
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Affiliation(s)
| | - Jacob Bornstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
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