Measuring treatment outcomes in women with vulvodynia

Does the addition of electrical stimulation or kinesiotherapy improve outcomes of amitriptyline treatment for women with vulvodynia? A randomized clinical trial

INTRODUCTION AND HYPOTHESIS

Women diagnosed with provoked vulvodynia frequently report a great deal of frustration in achieving symptomatic relief. Physical therapy and drug treatment are among the interventions most indicated by guidelines; however, whether those modalities are effective when combined remains unclear. The objective was to evaluate the effectiveness of adding a physical therapy modality compared with amitriptyline alone for the treatment of vulvodynia.

METHODS

Eighty-six women with vulvodynia were randomized to (G1) 25 mg amitriptyline, once a day (n=27), (G2) amitriptyline + electrical stimulation therapy (n=29) or (G3) amitriptyline + kinesiotherapy (n=30). All treatment modalities were administered for 8 weeks. The primary endpoint was the reduction in vestibular pain. Secondary measurements focused on sexual pain, frequency of vaginal intercourse, Friedrich score, and overall sexual function. Data were analyzed using intention-to-treat.

RESULTS

All treatment modalities resulted in a significant decrease in vestibular pain (p<0.001), sexual pain (p<0.05), Friedrich score (p<0.001), and an increase in the frequency of sexual intercourse (p<0.05). G3 was more effective than G1 at reducing sexual pain (G1: 5.3±3.3 vs G3: 3.2±2.7; p=0.01) and at improving sexual function (G1: 18.8±9.8 vs G3: 23.9±7.8; p=0.04).

CONCLUSION

Kinesiotherapy and electrotherapy additions to amitriptyline administration as well as amitriptyline alone, were effective at improving vestibular pain in women with vulvodynia. Women receiving physical therapy had the greatest improvement in sexual function and frequency of intercourse at post-treatment and follow-up.

Lactobacilli and Cytokine Modifications during Menopause and Their Relation to Vulvar and Vulvovaginal Disorders

OBJECTIVES

Female sexual and reproductive health is heavily influenced by the levels and ratios of Lactobacilli species and vaginal cytokines. Menopause marks a profound body change as it shifts to a natural and permanent non-reproductive state. Vulvovaginal diseases encompass a broad variety of sexual health conditions. Furthermore, both menopause and vulvovaginal diseases affect vaginal Lactobacilli and cytokine levels. Thus, this study aimed to investigate the correlation between menopause, vulvovaginal diseases, and vaginal Lactobacilli and cytokine levels.

METHODS

Vaginal swab samples were collected as part of a prospective data bank creation to study vaginal conditions as approved by the Institutional Review Board of Texas Tech University Health Sciences Center, Lubbock, USA. This study utilized 38 samples in this database, which were assigned to the pre-menopausal with no vulvovaginal conditions (n = 20) and post-menopausal with vulvovaginal conditions (n = 18) groups. A real-time polymerase chain reaction was conducted to determine the relative concentration of Lactobacilli species, while cytokine analysis was performed using multiplex enzyme-linked immunosorbent assay immunoassay. The standardized mean difference, multivariate analysis of variance, and permutational unequal variance t test were used for the statistical analysis.

RESULTS

Cytokines, interleukin (IL)-6, macrophage inflammatory protein-1α, IL-8, and Lactobacillus iners expression were significantly elevated in the control group compared to the study group (P = 0.03 for the cytokines, P = 0.0194 for Lactobacilli).

CONCLUSIONS

The levels of vaginal cytokine and Lactobacillus profile were significantly different between the pre-menopausal and post-menopausal groups.

Cytokine profiles and Lactobacillus species presence in pre-menopausal subjects with genital Mycoplasma genitalium or Ureaplasma urealyticum colonization

Background and Purpose:

Lactobacilli play a vital role in protecting the vagina against pathogens. Cytokines are vital components of defense against infections in women. The genital mycoplasmas, Mycoplasma genitalium and Ureaplasma urealyticum, are associated with various infectious diseases in adults and infants. The objective of our study is to identify differences in cytokine profile and Lactobacillus species dominance between a study group of non-pregnant pre-menopausal women with genital M. genitalium or U. urealyticum colonization and a control group of non-pregnant pre-menopausal women without genital M. genitalium or U. urealyticum colonization.

Methods:

A real-time polymerase chain reaction was performed to measure Lactobacillus species in vaginal swab samples. Cytokine analysis was performed using multiplex immunoassay techniques. Analysis of variance confirmed a significant difference in cytokine profiles between patient groups, with t-tests identifying the most significantly different cytokines. Categorical data analysis identified significant patterns of relative Lactobacillus species dominance in the study group.

Results:

Lactobacillus iners was the predominant Lactobacillus species in the control group (p = 0.005). There were no dominant Lactobacillus species observed in the study group. Vascular endothelial growth factor A (p = 0.002), interleukin-8 (p = 0.001), and interleukin-1β (p = 0.049) were expressed significantly higher in the study group, whereas interleukin-1 receptor antagonist (p < 0.001), interleukin-10 (p = 0.001), interleukin-12 (p = 0.002), and interferon-γ (p = 0.022) were expressed higher in the control group. Association matrices for cytokines were significantly different between two groups (p < 0.001), with mostly negative associations in the control group and mostly positive associations in the study group.

Conclusion:

Cytokine levels, their associations, and the patterns of Lactobacillus species dominance are observed to significantly diverge on the basis of M. genitalium and U. urealyticum colonization among non-pregnant pre-menopausal women.

Exploring Pain-Related Anxiety and Depression in Female Patients With Provoked Vulvodynia With Associated Overactive Pelvic Floor Muscle Dysfunction

Introduction

Vulvodynia is a chronic pain condition with potential associated factors, including musculoskeletal and psychosocial components.

Aim

This study explores the prevalence of pain-related anxiety and depression in women with provoked vestibulodynia with associated overactive pelvic floor muscle dysfunction (PVD-PFD).

Methods

A retrospective chart review of 352 women presenting to 2 urban vulvovaginal specialty clinics over the course of a year was conducted. Women presenting for initial evaluation completed validated questionnaires for pain-related anxiety and depression. Women who completed these questionnaires with a diagnosis of PVD-PFD independently confirmed by a women's health physical therapist were included in analysis. Information on previously attempted treatments was gathered.

Main Outcome Measures

Pain-related anxiety was measured with the Pain Anxiety Symptoms Scale-20 and depression with the Patient Health Questionnaire 8.

Results

Of 79 women with confirmed PVD-PFD, 22% met criteria for pain-related anxiety alone, 4% for depression alone, and 27% for both pain-related anxiety and depression, with a significant association between anxiety and depression (χ² (1) = 21.44, P < .0005, phi = 0.521). There was also a significant association between anxiety and/or depression and whether prior treatment was attempted (χ² (2) = 6.81, P = .03, phi = 0.294).

Conclusion

The study found that 49% of women with PVD-PFD experienced pain-related anxiety, with or without depression. In addition, there was a statistically significant association between attempts at prior treatment and greater pain-related anxiety and depression. This is the first study to report a rate of pain-related anxiety specifically in women with PVD-PFD. These findings are consistent with studies showing elevated pain-related anxiety in other chronic musculoskeletal conditions, including lower back pain and fibromyalgia.

Govind V, Krapf JM, Mitchell L, et al. Exploring Pain-Related Anxiety and Depression in Female Patients With Provoked Vulvodynia With Associated Overactive Pelvic Floor Muscle Dysfunction. J Sex Med 2020;8:517–524.

Vaginal Lactobacillus species and inflammatory biomarkers in pregnancy

BACKGROUND

The aim of this study was to identify vaginal Lactobacillus spp. and quantify vaginal inflammatory cytokines in primigravida vs. multigravida women and pregnant vs. non-pregnant women.

METHODS

Vaginal swabs were obtained from four groups of patients. A real-time PCR was carried out to identify the Lactobacillus spp. Multiplex immunoassays were performed to quantify a total of 27 cytokines using the Bio-Plex MAGPIX multiplex reader and MesoQuick Plex SQ 120 (Meso Scale Diagnostics LLC, Rockville, MD, USA). Inferential statistics using hypothesis tests were applied to detect differences in cytokine levels.

RESULTS

Significant differences in cytokines and chemokines exist among the four populations of women studied. IP-10 is significantly higher in multigravida women as compared to primigravida women. IFN-γ, MCP-1, MIP-1β, IL-2 and IL-10 are significantly higher in non-pregnant women compared to pregnant women. L. iners was the most abundant species in multigravida, pregnant and non-pregnant patients, while L. crispatus was the most abundant species in primigravida patients. Significant differences in the levels of MIP-1β, TNF-α, PDGF-BB, VEGF-A, IL-12, and IL-10 exist between women identified with Lactobacillus species and women not identified with Lactobacillus species.

CONCLUSIONS

There were significant differences regarding cytokines, chemokines, and Lactobacillus spp. among four groups of studied patients. With these results, we increase our understanding of the role that vaginal cytokines and Lactobacillus species have during pregnancy, with the goal that this novel research will be useful for examining vaginal biomarkers in obstetrical conditions.

Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report

BACKGROUND

A 28-y-old athletic woman was diagnosed with vulvodynia and long-term irritable bowel syndrome (IBS) and was treated successfully with an elimination diet.

CASE/INTERVENTION

In the course of 6 mo of nutrition therapy utilizing an elimination diet, specific foods triggering abdominal bloating and pain, and vulvovaginal pain were identified. In the course of treatment, the nutrition and supplement program instituted for this patient allowed her to return to her prior functional level without pain (including sexual activity) and resolution of her IBS. She has remained symptom free for at least 6 mo posttreatment.

CONCLUSION

This case demonstrates the potential usefulness of incorporating a customized nutritional approach to determine proinflammatory foods in patients with chronic vulvodynia and overlapping IBS. Long-term pain resolution and healthy sexual functioning in this case was supported by food elimination and nutritional supplementation.

A comparison of cognitive-behavioral couple therapy and lidocaine in the treatment of provoked vestibulodynia: study protocol for a randomized clinical trial

Background

Provoked vestibulodynia (PVD), a frequent form of chronic genital pain, is associated with decreased sexual function for afflicted women, as well as impoverished sexual satisfaction for women and their partners. Pain and sexuality outcomes for couples with PVD are influenced by interpersonal factors, such as pain catastrophizing, partner responses to pain, ambivalence over emotional expression, attachment style and perceived relationship and sexual intimacy. Despite recommendations in the literature to include the partner in cognitive-behavioral therapy targeted at improving pain and sexuality outcomes, no randomized clinical trial has tested the efficacy of this type of intervention and compared it to a first-line medical intervention.

Methods

This bi-center, randomized clinical trial is designed to examine the efficacy of cognitive-behavioral couple therapy compared to topical lidocaine. It is conducted across two Canadian university-hospital centers. Eligible women diagnosed with PVD and their partners are randomized to one of the two interventions. Evaluations are conducted using structured interviews and validated self-report measures at three time points: Pre-treatment (T1: prior to randomization), post-treatment (T2), and 6-month follow-up (T3). The primary outcome is the change in reported pain during intercourse between T1 and T2. Secondary outcomes focus on whether there are significant differences between the two treatments at T2 and T3 on (a) the multidimensional aspects of women’s pain and (b) women and partners’ sexuality (sexual function and satisfaction), psychological adjustment (anxiety, depression, catastrophizing, self-efficacy, and quality of life), relationship factors (partner responses and dyadic adjustment) and self-reported improvement and treatment satisfaction. In order to detect an effect size as small as 0.32 for secondary outcomes, a sample of 170 couples is being recruited (27% dropout expected). A clinically significant decrease in pain is defined as a 30% reduction.

Discussion

The randomized clinical trial design is the most appropriate to examine the efficacy of cognitive-behavioral couple therapy, a recently developed and pilot-tested psychosocial intervention for couples coping with PVD, in comparison to a frequent first-line treatment option, topical lidocaine. Findings from this study will provide important information about empirically supported treatment options for PVD, and inform future treatment development and research for this patient population.

Trial registration

Clinicaltrials.gov NCT01935063; registration date: 27 August 27 2013.