Menopause Leading to Increased Vaginal Wall Thickness in Women with Genital Prolapse: Impact on Sexual Response

Hormone therapy for sexual function in perimenopausal and postmenopausal women

BACKGROUND

The perimenopausal and postmenopausal periods are associated with many symptoms, including sexual complaints. This review is an update of a review first published in 2013.

OBJECTIVES

We aimed to assess the effect of hormone therapy on sexual function in perimenopausal and postmenopausal women.

SEARCH METHODS

On 19 December 2022 we searched the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Science, two trials registries, and OpenGrey, together with reference checking and contact with experts in the field for any additional studies.

SELECTION CRITERIA

We included randomized controlled trials that compared hormone therapy to either placebo or no intervention (control) using any validated assessment tool to evaluate sexual function. We considered hormone therapy: estrogen alone; estrogen in combination with progestogens; synthetic steroids, for example, tibolone; selective estrogen receptor modulators (SERMs), for example, raloxifene, bazedoxifene; and SERMs in combination with estrogen.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We analyzed data using mean differences (MDs) and standardized mean differences (SMDs). The primary outcome was the sexual function score. Secondary outcomes were the domains of sexual response: desire; arousal; lubrication; orgasm; satisfaction; and pain. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 36 studies (23,299 women; 12,225 intervention group; 11,074 control group), of which 35 evaluated postmenopausal women; only one study evaluated perimenopausal women. The 'symptomatic or early postmenopausal women' subgroup included 10 studies, which included women experiencing menopausal symptoms (symptoms such as hot flushes, night sweats, sleep disturbance, vaginal atrophy, and dyspareunia) or early postmenopausal women (within five years after menopause). The 'unselected postmenopausal women' subgroup included 26 studies, which included women regardless of menopausal symptoms and women whose last menstrual period was more than five years earlier. No study included only women with sexual dysfunction and only seven studies evaluated sexual function as a primary outcome. We deemed 20 studies at high risk of bias, two studies at low risk, and the other 14 studies at unclear risk of bias. Nineteen studies received commercial funding. Estrogen alone versus control probably slightly improves the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.50, 95% confidence interval (CI) (0.04 to 0.96; I² = 88%; 3 studies, 699 women; moderate-quality evidence), and probably makes little or no difference to the sexual function composite score in unselected postmenopausal women (SMD 0.64, 95% CI -0.12 to 1.41; I² = 94%; 6 studies, 608 women; moderate-quality evidence). The pooled result suggests that estrogen alone versus placebo or no intervention probably slightly improves sexual function composite score (SMD 0.60, 95% CI 0.16 to 1.04; I² = 92%; 9 studies, 1307 women, moderate-quality evidence). We are uncertain of the effect of estrogen combined with progestogens versus placebo or no intervention on the sexual function composite score in unselected postmenopausal women (MD 0.08 95% CI -1.52 to 1.68; 1 study, 104 women; very low-quality evidence). We are uncertain of the effect of synthetic steroids versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 1.32, 95% CI 1.18 to 1.47; 1 study, 883 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 0.46, 95% CI 0.07 to 0.85; 1 study, 105 women; very low-quality evidence). We are uncertain of the effect of SERMs versus control on the sexual function composite score in symptomatic or early postmenopausal women (MD -1.00, 95% CI -2.00 to -0.00; 1 study, 215 women; very low-quality evidence) and of their effect in unselected postmenopausal women (MD 2.24, 95% 1.37 to 3.11 2 studies, 1525 women, I² = 1%, low-quality evidence). We are uncertain of the effect of SERMs combined with estrogen versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.22, 95% CI 0.00 to 0.43; 1 study, 542 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 2.79, 95% CI 2.41 to 3.18; 1 study, 272 women; very low-quality evidence). The observed heterogeneity in many analyses may be caused by variations in the interventions and doses used, and by different tools used for assessment.

AUTHORS' CONCLUSIONS

Hormone therapy treatment with estrogen alone probably slightly improves the sexual function composite score in women with menopausal symptoms or in early postmenopause (within five years of amenorrhoea), and in unselected postmenopausal women, especially in the lubrication, pain, and satisfaction domains. We are uncertain whether estrogen combined with progestogens improves the sexual function composite score in unselected postmenopausal women. Evidence regarding other hormone therapies (synthetic steroids and SERMs) is of very low quality and we are uncertain of their effect on sexual function. The current evidence does not suggest the beneficial effects of synthetic steroids (for example tibolone) or SERMs alone or combined with estrogen on sexual function. More studies that evaluate the effect of estrogen combined with progestogens, synthetic steroids, SERMs, and SERMs combined with estrogen would improve the quality of the evidence for the effect of these treatments on sexual function in perimenopausal and postmenopausal women.

Liquid crystal elastomer based dynamic device for urethral support: Potential treatment for stress urinary incontinence

Stress urinary incontinence (SUI) is characterized by the involuntary loss of urine due to increased intra-abdominal pressure during coughing, sneezing, or exercising. SUI affects 20-40% of the female population and is exacerbated by aging. Severe SUI is commonly treated with surgical implantation of an autologous or a synthetic sling underneath the urethra for support. These slings, however, are static, and their tension cannot be non-invasively adjusted, if needed, after implantation. This study reports the fabrication of a novel device based on liquid crystal elastomers (LCEs) capable of changing shape in response to temperature increase induced by transcutaneous IR light. The shape change of the LCE-based device was characterized in a scar tissue phantom model. An in vitro urinary tract model was designed to study the efficacy of the LCE-based device to support continence and adjust sling tension with IR illumination. Finally, the device was acutely implanted and tested for induced tension changes in female multiparous New Zealand white rabbits. The LCE device achieved 5.6% ± 1.1% actuation when embedded in an agar gel with an elastic modulus of 100 kPa. The corresponding device temperature was 44.9 °C ± 0.4 °C, and the surrounding agar temperature stayed at 42.1 °C ± 0.4 °C. Leaking time in the in vitro urinary tract model significantly decreased (p < 0.0001) when an LCE-based cuff was sutured around the model urethra from 5.2min ± 1min to 2min ±0.5min when the cuff was illuminated with IR light. Normalized leak point force (LPF) increased significantly (p = 0.01) with the implantation of an LCE-CB cuff around the bladder neck of multiparous rabbits. It decreased significantly (p = 0.023) when the device was actuated via IR light illumination. These results demonstrate that LCE material could be used to fabricate a dynamic device for treating SUI in women.

Measurement of the vaginal wall thickness by transabdominal and transvaginal ultrasound of women with vaginal laxity: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

An objective diagnostic method to understand vaginal laxity (VL) is still missing. The aim of our study is to determine whether vaginal wall thickness (VWT) measured by ultrasound may differ according to the abdominal or vaginal techniques and to assess whether clinical variables are associated with vaginal measurements of women with VL.

METHODS

A cross-sectional study conducted at a tertiary hospital included 82 women aged ≥ 18 years with VL complaints assessed by the Vaginal Laxity Questionnaire. Women who reported severe comorbidities or vulvovaginal disorders, previous treatment for VL, and use of vaginal estrogen in the last 6 months were excluded. Participants reporting VL underwent transabdominal (TAUS) and transvaginal ultrasound (TVUS) and physical examination and answered validated questionnaires. Descriptive data were given as mean and standard deviation, median (range), and absolute and relative frequency. The significance level adopted for this study was 5%. Sample size calculation was not performed for the present study.

RESULTS

Mean age was 41.20 ± 8.64 years, and most participants were multiparous, with previous vaginal delivery and having vaginal intercourse. A statistically significant difference (up to 3 mm) between TAUS and TVUS measurements of the VWT was found in the proximal, middle-third, and distal compartments. A significant correlation was found between VWT and TAUS or TVUS in the mid-third and distal compartments.

CONCLUSION

A significant correlation was found between the VWT measurements in TVUS and TAUS. Our findings might give the health professional more possibilities for investigating VWT according to patient characteristics.

A Low-Cost, Easily Deployable Vesicovaginal Fistula Occluding Device for Providing Interim Continence

Vesicovaginal fistulas (VVFs), abnormal openings between the vagina and bladder, disrupt the lives of millions of people worldwide due to resulting incontinence and infections. VVFs are commonly treated with surgery after the fistula has had time to heal over several months. In low-resource areas, the immediate incontinence often leads to ostracization from the community, and can be devastating for the patient. To occlude the fistula and enable full continence until the patient is able to access surgery, we have designed a three-tiered silicone plug consisting of a bladder-dwelling disc, a mid-fistula disc, and a vagina-dwelling cross-shaped tapered plug, all supported on a central stem.

The device withstands typical expulsion forces from the bladder and does not leak under typical bladder filling or urination pressures. The maximum device expulsion force is 3.69 N and it is watertight up to 100 cmH2O or 9.8 kPa. It is designed to be easily deployed by trained community members without medical qualifications.

Relationship Between Genitourinary Syndrome of Menopause and 3D High-Frequency Endovaginal Ultrasound Measurement of Vaginal Wall Thickness

BACKGROUND

To date, there is no certain method for diagnosis of genitourinary syndrome of menopause (GSM) and vaginal atrophy.

AIM

We aim to evaluate vaginal wall thickness (VWT) using 3D high frequency endovaginal ultrasound (3D EVUS) in GSM and also to investigate whether there is any association between VWT and postmenopausal sexual dysfunction.

METHODS

Postmenopausal women applied for routine gynecologic examination were assessed at the Outpatient Clinic of Gynecology, Maltepe University Hospital. After pelvic examination, GSM symptoms were questioned for all women and vaginal health scoring tool was applied. Twenty women with GSM and 20 women without GSM were included in the study.

OUTCOMES

All patients filled in the Female Sexual Function Index (FSFI) and underwent 3D EVUS to evaluate VWT.

RESULTS

The women with GSM had significantly lower anterior and posterior VWT (P=.007 and P=.049, respectively). The total FSFI score, lubrication and pain sub-scores in patients with GSM was significantly lower than the patients without GSM. Anterior VWT was positively correlated with BMI and pain sub-score of FSFI (r=0.279, P=.047; r=0.344, P=.013, respectively). A significant negative correlation was detected between anterior vaginal VWT and age, time since menopause and satisfaction sub-score of FSFI (r=-0.332, P=.017; r=-0.354, P=.011; r=-0.301, P=.032, respectively). Posterior VWT was positively correlated with FSFI total score, arousal, lubrication and pain sub-scores (r=0.451, P=.001; r=0.437, P=.001; r=0.415, P=.002; r=0.335, P=.016; respectively).

CLINICAL IMPLICATIONS

Based on our results, measurement of VWT using 3D EVUS can be a useful non-invasive tool for the objective diagnosis of GSM.

STRENGTHS AND LIMITATIONS

Considering that only total vaginal thickness can be measured with traditional transabdominal and transvaginal techniques, the main strength of the study is the use of 3D EVUS for separate measurement of anterior and posterior VWT. The study has sufficient statistical power. The small sample size of study is the main limitation.

CONCLUSION

The 3D EVUS can be used for objective diagnosis of GSM and can also shed light on the causes of various sexual dysfunction symptoms in postmenopausal women, as it enables measuring the anterior and posterior walls of the vagina separately. Peker H, Gursoy A. Relationship Between Genitourinary Syndrome of Menopause and 3D High-Frequency Endovaginal Ultrasound Measurement of Vaginal Wall Thickness. J Sex Med 2021;18:1230-1235.

Erosion of soft tissue by polypropylene mesh products

Surgical mesh products made from polypropylene (PP) have been extensively used in the treatment of stress urinary incontinence, pelvic organ prolapse and other conditions. Since the onset of the use of such implants, major complications have been reported. Mesh erosion, where neighbouring tissues are worn from the rubbing of mesh, occurs in a significant number of cases. However, there is still a lack in literature exploring the mechanics of this phenomenon. In this study, a purpose-built apparatus was used to generate erosion in soft tissue (porcine muscle) through the application of a force and a reciprocating action. Four different commercial products were tested, all made from knitted PP fibres: Monarc™ Gynecare™ and Obtryx™ slings and Sutulene™ mesh sheet material. A PP suture and three PP sheets with different edge roughness were also tested. Large differences were found in the erosion rates. Significantly, we found that meshes in which the edge had been formed using heat to cause partial melting gave much higher rates of erosion than mechanically cut edges. Heat-formed edges tended to retain their shape whilst mechanically cut edges degraded by unravelling. Several features of the mesh edge appear to be significant, including roughness, flexibility and the tendency to degrade. Constant load (non-reciprocating) tests were also carried out, revealing that creep can also cause erosion. These findings have significance for the design of surgical mesh products to minimise their adverse effects.

The ewe as an animal model of vaginal atrophy and vaginal Er:YAG laser application

OBJECTIVE

In sheep of reproductive age, we aimed to document decrease in epithelial thickness, glycogen amount, and other vaginal changes after castration and the effect of Er:YAG laser as used clinically.

METHODS

On day 0, 16 sheep underwent ovariectomy. They were randomized to sham or three vaginal Er:YAG laser applications at monthly intervals. Primary outcome was vaginal epithelial thickness (d60, d71, d73, d77, and d160). Secondary outcomes included indicators of atrophy (vaginal health index = VHI), pH, cytology, morphology at the above time points, microcirculation focal depth (FD; d70 and d160), and at sacrifice (d160) vaginal dimensions and active and passive biomechanical testing.

RESULTS

Menopausal changes between 60 and 160 days after ovariectomy included a progressive decrease in epithelial thickness, in VHI, FD, glycogen, elastin content and vasculature, and an increase in pH and collagen content. In lasered animals, the first day a few white macroscopic foci were visible and an increase in pH was measured. Both disappeared within 3 days. Seven days after laser the epithelial thickness increased. At sacrifice (d160), there were no differences between sham and laser group in vaginal dimensions, morphometry, mitotic and apoptotic activity, active contractility, vaginal compliance, except for a lower blood vessel density in the lamina propria of the midvagina in the laser group.

CONCLUSIONS

In reproductive sheep, ovariectomy induces vaginal atrophy evidenced in different outcome measurements. Vaginal Er:YAG laser induced visual impact, a short-term increase in epithelial thickness yet no long-term changes compared to sham therapy in menopausal controls.

Dual-sectored transurethral ultrasound for thermal treatment of stress urinary incontinence: in silico studies in 3D anatomical models

The purpose of this study is to investigate the feasibility and performance of a stationary, non-focused dual-sectored tubular transurethral ultrasound applicator for thermal exposure of tissue regions adjacent to the urethra for treatment of stress urinary incontinence (SUI) through acoustic and biothermal simulations on 3D anatomical models. Parametric studies in a generalized tissue model over dual-sectored ultrasound applicator configurations (acoustic surface intensities, lateral active acoustic output sector angles, and durations) were performed. Selected configurations and delivery strategies were applied on 3D pelvic anatomical models. Temperature and thermal dose distributions on the target region and surrounding tissues were calculated. Endovaginal cooling was explored as a strategy to mitigate vaginal heating. The 75-90° dual-sectored transurethral tubular transducer (3.5 mm outer diameter (OD), 14 mm length, 6.5 MHz, 8.8-10.2 W/cm²) and 2-3-min sonication duration were selected from the parametric study for acoustic and biothermal simulations on anatomical models. The transurethral applicator with two opposing 75-90° active lateral tubular sectors can create two heated volumes for a total of up to 1.8 cm³ over 60 EM_43 °C, with at least 10 mm radial penetration depth, 1.2 mm urethral sparing, and no lethal damage to the vagina and adjacent bone (< 60 EM_43 °C). Endovaginal cooling can be applied to further reduce the vaginal wall exposure (< 15 EM_43 °C). Simulations on 3D anatomical models indicate that dual-sectored transurethral ultrasound applicators can selectively heat pelvic floor tissue lateral to the mid-urethra in short treatment durations, without damaging adjacent vaginal and bone tissues, as a potential alternative treatment option for stress urinary incontinence. Graphical abstract Schema for in silico investigation of transurethral ultrasound thermal therapy applicator for minimally invasive treatment of SUI.

Changes in Sexual Function Following Uphold Transvaginal mesh Surgery for the Treatment of Urogenital Prolapse

Uphold transvaginal mesh implantation is an option for treating pelvic organ prolapse (POP). This prospective cohort study aims to evaluate the effect of Uphold transvaginal mesh implantation on female sexual function. 205 women with symptomatic POP were recruited and evaluated pre-operatively and re- evaluated six months post-operatively in terms of anatomical restoration, quality of life influenced by urinary incontinence and female sexual function. 30 women eventually completed the assessments and been statistically evaluated. The main outcome focused on sexual function. In our study, we found that Uphold transvaginal mesh surgery could achieve effective anatomical restoration of POP and better sexual function regardless of concomitant sling surgery.

Merkel-like cell distribution in the epithelium of the human vagina. An immunohistochemical and TEM study

Human Merkel cells (MCs) were first described by Friedrich S. Merkel in 1875 and named "Tastzellen" (touch cells). Merkel cells are primarily localized in the basal layer of the epidermis and concentrated in touch-sensitive areas. In our previous work, we reported on the distribution of MCs in the human esophagus, so therefore we chose other parts of the human body to study them. We selected the human vagina, because it has a similar epithelium as the esophagus and plays very important roles in reproduction and sexual pleasure. Due to the fact that there are very few research studies focusing on the innervation of this region, we decided to investigate the occurrence of MCs in the anterior wall of the vagina. The aim of our research was to identify MCs in the stratified squamous non-keratinized epithelium of the human vagina in 20 patients. For the identification of Merkel cells by light microscopy, we used antibodies against simple-epithelial cytokeratins (especially anti-cytokeratin 20). We also tried to identify them using transmission electron microscopy. Our investigation confirmed that 10 (50 %) of 20 patients had increased number of predominantly intraepithelial CK20 positive "Merkel-like" cells (MLCs) in the human vaginal epithelium. Subepithelial CK20 positive MLCs were observed in only one patient (5%). We tried to identify them also using transmission electron microscopy. Our investigation detected some unique cells that may be MCs. The purpose of vaginal innervation is still unclear. There are no data available concerning the distribution of MCs in the human vagina, so it would be interesting to study the role of MCs in the vaginal epithelium, in the context of innervation and epithelial biology.

Does the vaginal wall become thinner as prolapse grade increases?

INTRODUCTION AND HYPOTHESIS

The pathophysiology of prolapse is not well understood. However, two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated. The aim of this study was to assess how vaginal wall thickness (VWT) is related to vaginal prolapse.

METHODS

The study group comprised 243 women with symptomatic prolapse recruited from the Outpatient Department of a tertiary referral centre for urogynaecology. A history was taken and women were examined to determine their POP-Q score. Using a previously validated technique, ultrasonography was used to measure the mean VWT at three anatomical sites on the anterior and posterior walls. Scores were then compared using t tests, the Kruskal-Wallis test and the Friedman test.

RESULTS

The mean age of the patients was 59.7 years (SD 12.0 years range 38 - 84 years). For each measurement VWT reduced as prolapse grade increased until the prolapse extended beyond the hymen. Women with grade 3 prolapse had a significantly higher mean VWT than women with grade 1 or 2 contained prolapse. Menopause status did not have a significant effect on the VWT.

CONCLUSIONS

VWT is lower in women with vaginal prolapse until the prolapse extends beyond the hymen and then VWT is thicker and comparable with women without prolapse. This may be explained by changes in the vaginal tissue including reduction of collagen, elastin and smooth muscle, as well as fibrosis in exposed tissues, rather than by defects in the vagina.

Critical Review: Mechanisms of HIV Transmission in Depo-Provera Users: The Likely Role of Hypoestrogenism

Almost half of new HIV infections worldwide occur in women, and vaginal intercourse is the most common mode of transmission. Accumulating evidence suggests that depot medroxyprogesterone acetate may increase HIV transmission, but little is known about the underlying mechanisms. We propose that hypoestrogenism in depot medroxyprogesterone acetate may contribute to increased HIV transmission. We present supportive evidence and propose potential interventions to prevent or treat vaginal hypoestrogenism using vaginal estrogens.

Urogenital consequences in ageing women

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

Histology of the vaginal wall in women with pelvic organ prolapse: a literature review

INTRODUCTION AND HYPOTHESIS

The pathophysiology of pelvic organ prolapse (POP) is incompletely understood. The purpose of this study is to describe the current knowledge about histology of the vaginal wall and its possible involvement in the pathogenesis of pelvic organ prolapse.

METHODS

Eligible studies were selected through a MEDLINE search covering January 1986 to December 2012. The research was limited to English-language publications.

RESULTS

Investigations of changes in the vaginal tissue that occur in women with genital prolapse are currently still limited and produced contrary results. The heterogeneity of the patients and the control groups in terms of age, parity and hormonal status, of the localization of biopsies and the histological methods as well as the lack of validation of the quantification procedures do not allow clear and definitive conclusions to be drawn.

CONCLUSIONS

This review shows that current knowledge of the histological changes observed in women with POP are inconclusive and relatively limited. More studies are needed in this specific field to better understand the mechanisms that lead to POP.

Expression of aquaporin proteins in vagina of diabetes mellitus rats

INTRODUCTION

Aquaporins (AQPs) are membrane proteins that facilitate water movement across biological membranes. Vaginal lubrication may be mediated by blood flow and other potential mechanisms related to transudation of fluid. The most common female sexual dysfunction in diabetes is inadequate vaginal lubrication.

AIM

To investigate the expression of AQP1-3 in vaginal tissue of diabetes mellitus rats.

METHODS

Female Sprague-Dawley rats (N = 20) were randomly divided into group A (12-week-old nondiabetic control, N = 5), group B (16-week-old nondiabetes control, N = 5), group C (12-week-old diabetes mellitus rats, N = 5), and group D (16-week-old diabetes mellitus rats, N = 5). Vaginal fluid was measured by fluid weight absorbed by cotton swabs after pelvic nerve electrostimulation and anterior vaginal tissue was dissected for determining the expression of AQP1-3 by immunohistochemical study and Western blot.

MAIN OUTCOME MEASURES

The expression of AQP1-3 was determined in the vagina of diabetes mellitus rats by Western blot.

RESULTS

There are no significant differences in serum estradiol concentrations of rats among these groups (P > 0.05). Vaginal fluid was significantly lower in group C (2.7 ± 0.67 mg) and group D (2.5 ± 1.03 mg) than in group A (5.74 ± 1.23 mg) and group B (5.5 ± 1.08 mg) (P < 0.05), respectively. The protein expressions of AQP1-3 were significantly lower in group C (43.40 ± 4.83, 60.60 ± 12.80, and 59.60 ± 6.95) and group D (20.81 ± 2.86, 47.80 ± 11.43, and 54.20 ± 5.26) than in group A (116.62 ± 3.21, 110.81 ± 8.044, and 108.80 ± 4.97) and group B (122.12 ± 14.54, 111.21 ± 15.07, and 106.40 ± 4.16) (P < 0.05), respectively.

CONCLUSIONS

Decreased vaginal fluid in diabetes mellitus rats after electrostimulation may be partly due to estrogen-independent decreases of AQP1-3 in vaginal tissue.

Changes in female sexual function following anterior with and without posterior vaginal mesh surgery for the treatment of pelvic organ prolapse

INTRODUCTION

Comparison of female sexual function following anterior and total transvaginal mesh (TVM) surgery has never been reported.

AIM

To compare the sexual function after anterior and total TVM repair for the treatment of pelvic organ prolapse (POP).

MAIN OUTCOME MEASURES

The short forms of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), and the Female Sexual Function Index (FSFI).

METHODS

One hundred and sixty-five women with symptomatic POP stages II to IV defined by the POP quantification (POP-Q) staging system underwent TVM procedures at our hospitals. Seventy women were included because they were sexually active and had complete follow-up. All subjects were divided into the anterior group (anterior TVM; N=39) and total group (anterior and posterior TVM; N=31). Preoperative and postoperative assessments included pelvic examination using the POP-Q system, urodynamic study, and a personal interview to evaluate urinary and sexual symptoms with the short forms of UDI-6 and IIQ-7, and the FSFI.

RESULTS

There was no difference between the two groups as for age, parity, diabetes, hypertension, concomitant procedures, and success rates for TVM and mid-urethral sling in this study (P>0.05). Regarding the POP-Q analysis, there was a significant improvement at points Aa, Ba, C, Ap, and Bp (P<0.05) in both groups except for total vaginal length (P>0.05). The preoperative scores of UDI-6 and IIQ-7 were significantly higher in the total group (P<0.01), and the UDI-6 and IIQ-7 scores showed significant decreases in both groups postoperatively (P<0.01). After TVM surgery, the score of the dyspareunia domain worsened significantly in both groups (P<0.05), and the deteriorated lubrication domain was noted only in the total group (P=0.042).

CONCLUSIONS

TVM procedure creates an effective anatomical restoration of POP, but individual domains of FSFI may worsen. Compared with the anterior group, women of the total group had worse quality of life in term of urinary symptoms preoperatively, and experienced a greater sexual impairment on lubrication following surgery.

Vaginal microbiome and epithelial gene array in post-menopausal women with moderate to severe dryness

After menopause, many women experience vaginal dryness and atrophy of tissue, often attributed to the loss of estrogen. An understudied aspect of vaginal health in women who experience dryness due to atrophy is the role of the resident microbes. It is known that the microbiota has an important role in healthy vaginal homeostasis, including maintaining the pH balance and excluding pathogens. The objectives of this study were twofold: first to identify the microbiome of post-menopausal women with and without vaginal dryness and symptoms of atrophy; and secondly to examine any differences in epithelial gene expression associated with atrophy. The vaginal microbiome of 32 post-menopausal women was profiled using Illumina sequencing of the V6 region of the 16S rRNA gene. Sixteen subjects were selected for follow-up sampling every two weeks for 10 weeks. In addition, 10 epithelial RNA samples (6 healthy and 4 experiencing vaginal dryness) were acquired for gene expression analysis by Affymetrix Human Gene array. The microbiota abundance profiles were relatively stable over 10 weeks compared to previously published data on premenopausal women. There was an inverse correlation between Lactobacillus ratio and dryness and an increased bacterial diversity in women experiencing moderate to severe vaginal dryness. In healthy participants, Lactobacillus iners and L. crispatus were generally the most abundant, countering the long-held view that lactobacilli are absent or depleted in menopause. Vaginal dryness and atrophy were associated with down-regulation of human genes involved in maintenance of epithelial structure and barrier function, while those associated with inflammation were up-regulated consistent with the adverse clinical presentation.

Genital manifestation of graft-vs.-host disease: a series of case reports

INTRODUCTION

After hematopoietic stem cell transplantation (HSCT), many patients present genital graft-vs.-host disease (GVHD) that can culminate with sexual problems, which are poorly dimensioned.

AIM

We hope to draw attention to the need to perform genital biopsy to diagnose genital GVHD, and thus to call attention to the need to incorporate careful attention to sexual health in the treatment of these patients.

METHODS

Five allogeneic stem cell transplant recipients complaining of coital pain after HSCT were clinically diagnosed for genital GVHD. Genital biopsies were given for histological analysis, and microphotographs of the corresponding marked field in the slide were taken. Specimens were evaluated by the site pathologist and then sent to a reference pathologist, each blinded to the histological findings. A literature search was performed in PubMed/MEDLINE (1966-2009) for cross-sectional and cohort studies or trials related to genital GVHD. Expert opinions peer reviews and case reports were also considered.

MAIN OUTCOME MEASURES

HSCT, genital GVHD, genital biopsy.

RESULTS

The biopsy showed evidence of dilated apoptotic cells in the basal layer and detachment of the epithelial lining of the mucosa, hyalinization and thickening of collagen fibers, capillary ectasia, and mononuclear inflammatory infiltrate of the submucosa. Three patients presented vulval lesion such as leucoplasia and ulcer on the large lip. Histological analyses showed evidence of epithelial hyperplasia and influx of inflammatory cells to the epithelial surface, intercellular edema and spongiosis, apoptotic bodies on the basal layer of the epithelium, spongiosis, and nuclear vacuolization. A common treatment based on corticotherapy resulted in complete remission of coetaneous or mucous genital lesions in all five patients.

CONCLUSION

Genital biopsy is important to differentially diagnose GVHD and secondary symptoms due to hypoestrogenism. Prevention is the most important step in controlling the evolution GVHD in the vagina to prevent vaginal obstruction and sexual dysfunction.