Development of a core outcome set for treatment studies for provoked vestibulodynia

BACKGROUND

There is an inconsistency in treatment outcomes used in clinical trials for provoked vestibulodynia (PVD), which makes it impossible to compare the effects of different interventions.

AIM

In this study, we completed the first step in creating a core outcome set (COS), defining what outcomes should be measured in clinical trials for PVD.

METHODS

Identification of outcomes used in studies was done by extracting data from clinical trials in a recently published systematic review and via review of clinical trials for PVD registered on ClinicalTrials.gov. The COS process consisted of 2 rounds of Delphi surveys and a consensus meeting, during which the final COS was decided through a modified nominal group technique.

OUTCOMES

Consensus on what outcomes to include in a COS for PVD.

RESULTS

Forty scientific articles and 92 study protocols were reviewed for outcomes. Of those, 36 articles and 25 protocols were eligible, resulting in 402 outcomes, which were then categorized into 63 unique outcomes. Participants consisted of patients, relatives/partners of patients, health care professionals, and researchers. Out of 463 who registered for participation, 319 and 213 responded to the first and second surveys, respectively. The consensus meeting consisted of 18 members and resulted in 6 outcomes for the COS to be measured in all treatment trials regardless of intervention: insertional pain (nonsexual), insertional pain (sexual), provoked vulvar pain by pressure/contact, pain-related interference on one's life, pain interference on sexual life, and sexual function.

CLINICAL IMPLICATIONS

Critical outcomes to be measured in clinical trials will allow for accurate comparison of outcomes across treatment interventions and provide solid treatment recommendations.

STRENGTHS AND LIMITATIONS

The major strengths of the study are the adherence to methodological recommendations and the intentional focus on aspects of diversity of participating stakeholders (eg, status such as patients with lived experience and researchers, inclusiveness with respect to sexual identity), the latter of which will allow for broader application and relevance of the COS. Among the limitations of the study are the low rate of participants outside North America and Europe and the lower response rate (about 50%) for the second Delphi survey.

CONCLUSION

In this international project, patients, health care professionals, and researchers have decided what critical outcomes are to be used in future clinical trials for PVD. Before the COS can be fully implemented, there is also a need to decide on how and preferably when the outcomes should be measured.

Guided internet-based acceptance and commitment therapy for provoked vestibulodynia: A randomized controlled trial

BACKGROUND

Provoked vestibulodynia (PVD) causes suffering in many women's lives due to its impact on relationships, sexual functioning and functioning in other key domains.

OBJECTIVE

Here, we report a randomized controlled trial conducted to examine whether Acceptance and Commitment Therapy (ACT) with a focus on values-based exposure, delivered online, benefits women with PVD.

METHODS

Participants (n = 88) were randomized to either guided online ACT for 10 weeks or a wait-list control group. Outcomes were assessed at baseline, post treatment and 1 year later. Analyses were based on intention to treat using linear mixed models.

RESULTS

There were significant group differences on the primary outcomes, Female Sexual Index and Female Sexual Distress Scale, in favour of online ACT with moderate effect sizes. Differences were also found on several secondary outcomes and therapeutic process measures, all in favour of ACT. No differences were found at post-treatment for depression or anxiety. At the 1-year follow-up, results were maintained and a difference between baseline and follow-up was also found for depression.

CONCLUSION/SIGNIFICANCE

In summary, a relatively brief, guided, online version of ACT appears to produce benefits for women with PVD and related impacts on daily functioning. 50% to 60% of the women who participated in the treatment reliably improved in sexual functioning and distress.

The Association Between Immune-Related Conditions Across the Life-Course and Provoked Vulvodynia

Vulvodynia, impacts up to 8% of women by age 40, and is hypothesized to manifest through an altered immune-inflammatory response. To test this hypothesis, we identified all women born in Sweden between 1973 and 1996 diagnosed with localized provoked vulvodynia (N76.3) and/or vaginismus (N94.2 or F52.5) between 2001 and 2018. We matched each case to two women from the same birth year with no vulvar pain ICD codes. As a proxy for immune dysfunction, we used Swedish Registry data to capture 1) immunodeficiencies, 2) single organ and multiorgan autoimmune conditions, 3) allergy and atopies, and 4) malignancies involving immune cells across the life course. Women with vulvodynia, vaginismus or both were more likely to experience immune deficiencies (OR 1.8, 95% CI, 1.2-2.8), single organ (OR 1.4, 95% CI, 1.2-1.6) and/or multi-organ (OR 1.6, 95% CI, 1.3-1.9) immune disorders, and allergy/atopy conditions (OR 1.7, 95% CI, 1.6-1.8) compared to controls. We observed greater risk with increasing numbers of unique immune related conditions (1 code: OR = 1.6, 95% CI, 1.5-1.7; 2 codes: OR = 2.4, 95% CI, 2.1-2.9; 3 or more codes: OR = 2.9, 1.6-5.4). These findings suggest that women with vulvodynia may have a more compromised immune system either at birth or at points across the life course than women with no vulvar pain history. PERSPECTIVE: Women with vulvodynia are substantially more likely to experience a spectrum of immune related conditions across the life course. These findings lend support to the hypothesis that chronic inflammation initiates the hyperinnervation that causes the debilitating pain in women with vulvodynia.

Health economic evaluation of a randomized controlled trial (EMBLA study), an internet-based treatment for provoked vulvodynia

Internet-based treatment (IBT) for provoked vulvodynia (PVD) may reduce pain during intercourse and increases pain acceptance. However, a there is still a knowledge gap regarding the cost-effectiveness of IBT for PVD. The aim of this study was to perform a health economic evaluation of guided internet-based intervention for PVD as an addition to standard treatment. The sample consisted of 99 women with a PVD diagnosis. Healthcare related costs, health-related quality of life, and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were analyzed. After the IBT, the intervention group had fewer visits to a midwife than the control group (p = 0.03), but no between-group differences were found for visits to other professionals, treatment length, health-related quality of life, QALYs, and costs for treatment. It was estimated a cost of 260.77 € for a clinical meaningful change in pain acceptance. Internet-based treatment as add-on to clinical treatment may lower number of visits to a healthcare.

Botulinum Toxin a for Provoked Vestibulodynia: 12 Months' Follow-Up of a Randomized Controlled Trial

BACKGROUND

Provoked vestibulodynia (PVD) is a common pain disorder afflicting primarily young women, and botulinum toxin A (BTA) has been to a limited extent tested as a treatment.

AIM

Evaluate outcome 12 months after injection with BTA as a treatment for PVD.

METHODS

We conducted a double-blinded, placebo-controlled trial of twice repeated injections of 50 units of BTA or placebo in the bulbocavernosus muscles, 3 months apart, in women with PVD. Treatment outcome after six months', failed to show any significant difference in pain reduction between the groups, as previously reported. Here, we report treatment outcomes 12 months after the first injections. In addition to injections, participants where instructed to perform pelvic floor exercises during month 6-12. 38 participants/group was calculated to achieve a statistical power of 80% based on an effect size of 20 VAS units (mean score range 56-76±31 SD).

OUTCOMES

Primary outcome was self-reported dyspareunia or pain at tampon use, using a visual analogue scale (VAS) 0-100. Secondary outcomes were vaginal pressure measurements, psychological health, sexual function and distress.

RESULTS

From the initial 88 randomized women with PVD, 75 remained at 12 months; 38 in the BTA and 37 in the placebo group. There was no significant difference in primary outcome between the groups. Vaginal pressure in the BTA group had been restored to pre-treatment levels, with no differences between the groups at 12 months. There was an increase in sexual function in the BTA group, with a Female Sexual Function Index of 22.8 (±4.8) compared to the placebo group to 19.7 (±5.0), P=.048. No differences were observed in sexual distress, stress and anxiety. There was an increase in number of women attempting intercourse in the BTA group (74%) compared with placebo (43%), P=.005. Too few patients performed the pelvic floor exercises for this intervention to be analyzed.

CLINICAL IMPLICATIONS

This study highlights BTA as a safe treatment option for patients with PVD.

STRENGTHS AND LIMITATIONS

The randomized, double-blinded design and repeated treatments are the major strengths of this study and it is the first study to objectively evaluate muscular effect after BTA injections. The major shortcoming is that few participants performed the pelvic floor exercises, preventing analyses.

CONCLUSION

At 12 months' follow up, no significant difference in reduction of dyspareunia or pain at tampon use was observed. Women receiving BTA attempted intercourse more often and improved their sexual function compared with women receiving placebo.

Interpregnancy interval and maternal and neonatal morbidity: a nationwide cohort study

This study aimed to assess the association between interpregnancy interval (IPI)-the time from childbirth to conception of the next pregnancy-and maternal and neonatal morbidity. The World Health Organization (WHO) currently recommends an IPI of at least 24 months after a live birth to reduce adverse birth outcomes. However, assessing the relationship between IPI and perinatal outcome is complicated by confounding factors. We conducted a nationwide population-based cohort study using Swedish registry data, allowing for adjustment of maternal characteristics and health at first birth. The study population consisted of all women with a singleton, live, and vaginal first birth with a second singleton birth within five years during 1997-2017, covering 327,912 women and 655,824 neonates. IPI was grouped into six-month intervals with 24-29 months as the reference. The association between IPI and morbidity was examined using multivariate logistic regression. For women having a vaginal delivery at their first birth, intervals < 24-29 months were associated with decreased maternal morbidity and unaffected neonatal morbidity. Intervals > 24-29 months were associated with increased maternal and neonatal morbidity. Our findings question the relevance of WHO's recommendation of an IPI of at least 24 months in a high-income country.

Experiences of internet-based treatment for vulvodynia: A qualitative study

OBJECTIVE

The aim of this study was to describe women's experiences before, under, and after a guided internet-based intervention for vulvodynia.

METHODS

The design was qualitative, based on content analysis. Participants were women who had undergone guided internet-based treatment for vulvodynia based on acceptance and commitment therapy principles (n = 13). Data were collected through in-depth interviews approximately-one month after participants completed treatment.

RESULTS

The analysis revealed the women's experiences of internet-based treatment for vulvodynia. Three themes emerged: "dealing with pain alone," which was related to experiences of living with vulvodynia before internet-based treatment; "finding new ways," which described the experiences of undergoing an internet-based treatment for vulvodynia and "feeling empowered to take control," referring to the experiences of living with vulvodynia after the internet-based treatment. The women described a long search for a diagnosis, revealing a negative experience of healthcare. The internet-based treatment helped them find new ways to manage vulvodynia, but difficulties with the treatment were also experienced. After the intervention, the women reported improvements in wellbeing and having better strategies to manage pain, but also stated that the treatment was insufficient to perceive changes in vulvar pain.

CONCLUSIONS

The guided internet-based treatment program for vulvodynia based on acceptance and commitment therapy principles was perceived as credible, helpful to manage vulvodynia, and could serve as a complement to regular care. Questions regarding the need for more support and optimal length of treatment need to be further evaluated.

Treatment of Provoked Vulvodynia: A Systematic Review

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.

Delivery mode and severe maternal and neonatal morbidity among singleton term breech births: A population-based cohort study

OBJECTIVE

The aim of this study was to examine the association between delivery mode and severe maternal and neonatal morbidity in singleton term breech births.

STUDY DESIGN

This nationwide population-based cohort study includes 41 319 singleton term and post-term breech births (37 + 0-42 + 6 gestational weeks) in Sweden from 1998 to 2016. Data was retrieved from the Swedish Medical Birth Register. The primary outcomes were two separate composite outcomes, maternal and neonatal severe morbidity. Secondary outcomes were separate severe maternal and neonatal morbidity outcomes. Hospitalization and out-patient visits during childhood were also analyzed in ages 0-5 years. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI) of severe maternal and neonatal morbidity in women with vaginal breech birth or intrapartum cesarean section. Women with a prelabor breech cesarean section was used as the reference group.

RESULTS

No difference between vaginal delivery and prelabor cesarean section was seen regarding maternal morbidity. Intrapartum cesarean section was associated with elevated odds for maternal morbidity (aOR 1.27, 95% CI 1.10-1.47) compared with prelabor cesarean section. A similar result was observed for vaginal delivery and intrapartum cesarean section combined (aOR 1.29, 95% CI 1.11-1.50). Vaginal delivery was associated with higher odds for composite neonatal morbidity (aOR 1.85, CI 1.54-2.21) and most separate outcomes, as well as increased number of hospital nights and out-patient visits during first year of life, compared with prelabor cesarean section.

CONCLUSIONS

Prelabor cesarean section in breech births improved short-term neonatal health without increasing risks for severe maternal short-term complications.

Internet-based Treatment for Vulvodynia (EMBLA) - A Randomized Controlled Study

BACKGROUND

Internet-based ACT (Acceptance and commitment therapy) treatment may improve accessibility and reduce stigma related to seeking health care, but there are a lack of studies investigating internet-based treatment using ACT principles for women with vulvodynia.

AIM

The aim of this study was to investigate the effects of an internet-based treatment of pain during intercourse for women with provoked vulvodynia compared with no intervention during the waiting period before clinical treatment.

METHODS

A multicenter randomized controlled trial was conducted during 2016 to 2020, in which 99 participants were included. Participants were randomized to either a 6 week guided internet-based treatment using ACT principles or usual care. Data were collected at baseline, 6 weeks after baseline, and approximately 10 months after baseline.

OUTCOMES

Pain-related (pain during intercourse, tampon test, impact of pain on sexual function) and pain behavior-related outcomes (attempts at intercourse, sexual activities besides intercourse, willingness to perform the tampon test, chronic pain acceptance questionnaire) were used as outcomes.

RESULTS

Treatment was efficacious in what concerns pain during intercourse and pain acceptance. Less pain during intercourse among women in the intervention group was observed at both post-treatment (primary endpoint, P = .01, Cohen's d = 1.4, 95% CI = 0.33, 2.4), and follow-up (P = .04). Absolut mean difference between groups for pain during intercourse at post-treatment was -2.84, (95 % CI = -4.91, -0.78), and -1.58 at follow-up, (95 % CI = -3.17, 0.02), where the intervention group rated less pain than controls. No differences between groups over time were found for tampon test measures or impact of pain on sexual function. There was a significant difference between groups at all timepoints indicating fewer attempts at intercourse among participants in the intervention group. At post-treatment, women who underwent internet-based treatment reported higher pain acceptance and a rise in activity engagement compared with the control group.

CLINICAL IMPLICATIONS

There is an indication that internet-based treatment could be incorporated into clinical practice as a complement to clinical treatment.

STRENGTHS & LIMITATIONS

Study strengths included using several forms of recruitment and an intervention built by different professions with long experience of treating patients with vulvodynia. High dropout rate was a limitation of this study.

CONCLUSION

Internet-based treatment may have an impact on pain during intercourse and positive effects on pain acceptance. However, conclusions must be drawn with caution due to the small sample size. Engström AH, Bohm-Starke N, Kullinger M, et al. Internet-based Treatment for Vulvodynia (EMBLA) - A Randomized Controlled Study. J Sex Med 2022;19:319-330.

Early Life Health in Women with Provoked Vestibulodynia and/or Vaginismus

Background: The lifetime prevalence of prolonged vulvar pain ranges from 3% to 28% among premenopausal women. Provoked vestibulodynia (PVD), often accompanied with various degrees of vaginismus, is the predominant cause. We explored the association between birth-related events and the risk of developing PVD/vaginismus during adulthood. Materials and Methods: We identified all women born in Sweden between 1973 and 2001 and categorized those with and without a diagnosis of PVD/vaginismus between 2001 and 2016 (during ages 15-43 years). Nationwide registry data were used to estimate the association between health during infancy (preterm birth, low birth weight, small for gestational age [SGA], Appearance, Pulse, Grimace, Activity and Respiration [APGAR] scores <7, and pain exposure during infancy) and the onset of PVD/vaginismus later in life using an event probability model. Results: Of the 1,359,315 women born in Sweden during 1973-2001, 9,247 were diagnosed with PVD (n = 6,648), vaginismus (n = 3,567), or both (n = 969). Preterm delivery <37 weeks (adjusted odds ratios [aOR]: 1.15, 95% confidence interval [CI]: 1.05-1.26), low birth weight <2,500 g (aOR: 1.24, 95% CI: 1.12-1.36), extremely low birth weight <1,500 g (aOR 1.41, 95% CI: 1.10-1.82), and SGA (aOR 1.20, 95% CI: 1.08-1.34) were factors associated with developing PVD/vaginismus. APGAR scores <7 or pain exposure during birth or infancy was not associated with PVD/vaginismus. Advanced maternal age, higher educational attainment, and being born in Sweden were associated with having a female offspring diagnosed with PVD/vaginismus. Conclusions: In a population of Swedish women 15-43 years of age, adverse health at birth was associated with developing PVD/vaginismus later on in life.

Anti-biofilm activity of chlorhexidine digluconate against Candida albicans vaginal isolates

OBJECTIVES

Recurrent vulvovaginal candidiasis (RVVC) causes significant morbidity. Candida albicans is the main pathogen associated with both sporadic and recurrent candidiasis. Due to unsatisfactory treatment effect, the impact of chlorhexidine digluconate and fluconazole alone or in combination on C. albicans and biofilm was investigated.

METHODS

Vaginal C. albicans isolates from 18 patients with recurrent candidiasis and commensals from 19 asymptomatic women were isolated by culture. Crystal violet, XTT and colony forming unit assay were used to analyze the effect of chlorhexidine digluconate and fluconazole on growth of C. albicans, formation of new and already established, mature, biofilm.

RESULTS

Fluconazole reduced the growth of planktonic C. albicans. However, in established biofilm, fluconazole had no effect on the candida cells and was not able to disperse and reduce the biofilm. By contrast, chlorhexidine digluconate had a direct killing effect on C. albicans grown both planktonically and in biofilm. Chlorhexidine digluconate also dispersed mature biofilm and inhibited formation of new biofilm. No major differences were observed between commensal isolates and candida causing recurrent vulvovaginitis with respect to biofilm or growth after chlorhexidine digluconate treatment.

CONCLUSION

Biofilm is a problem in patients with recurrent vulvovaginal candidiasis reducing the effect of antifungal treatment. Development of new treatment strategies are urgently needed to decrease the recurrences. In already established biofilm, chlorhexidine digluconate dispersed the biofilm and was more effective in eradicating candida compared to fluconazole. Future treatment strategy may thus be a combination of chlorhexidine digluconate and fluconazole and prophylactic use of chlorhexidine digluconate to prevent biofilm formation and restrict infections.

Sex steroid hormone receptor expression in the vaginal wall in cervical cancer survivors after radiotherapy

Background: Sex steroid hormones and their receptors are important in female sexual function. The aim of this study was to investigate the expression and distribution of estrogen receptor (ER)α, ERβ, G-protein-coupled ER-1 (GPER), androgen receptor (AR), progesterone receptor (PR)A, PRB and connective tissue growth factor (CTGF) in the vaginal wall among women who had been treated for cervical cancer with radiotherapy. Material and methods: We included cervical cancer survivors treated with radiotherapy and premenopausal control women of the same age scheduled for benign gynecological surgery. We analyzed the expression and distribution of sex steroid hormone receptors and CTGF in biopsies from the vaginal wall, by real-time PCR and immunohistochemistry (IHC). Serum samples were analyzed for hormone levels and radiation dose at biopsy site were calculated and correlated to levels of the sex steroid hormone receptors. Results: In the cervical cancer survivors (n = 34), we found a lower expression of ERα at both mRNA and protein levels, compared to the control women (n = 37). In the survivors with high radiation dose at biopsy site, the immunostaining of ERα and AR was lower in the epithelium and the stroma, compared to survivors with minimal radiation dose. The later group showed expression of ERα comparable to the control women. The cancer survivors were sufficiently substituted with systemic estradiol with no difference in the serum estradiol levels compared to control women. Conclusions: We found that external radiation reduces the ERα and AR protein expression in the vaginal mucosa, indicating that the vaginal changes in irradiated cervical cancer survivors and the lack of response to hormonal treatment could be due to the decreases in sex steroid hormone receptor expression.

Psoriasin, a novel anti-Candida albicans adhesin

Abstract

Candida albicans belongs to the normal microbial flora on epithelial surfaces of humans. However, under certain, still not fully understood conditions, it can become pathogenic and cause a spectrum of diseases, from local infections to life-threatening septicemia. We investigated a panel of antimicrobial proteins and peptides (AMPs), potentially involved in mucosal immunity against this pathogen. Out of six studied AMPs, psoriasin was most up-regulated during a mucosal infection, an acute episode of recurrent Candida vulvovaginitis, although candidacidal activity has not been demonstrated. We here show that psoriasin binds to β-glucan, a basic component of the C. albicans cell wall, and thereby inhibits adhesion of the pathogen to surfaces and increases IL-8 production by mucosal epithelial cells. In conclusion, we show a novel mechanism of action of psoriasin. By inhibiting C. albicans adhesion and by enhancing cytokine production, psoriasin contributes to the immune response against C. albicans.

Key messages

The antimicrobial peptide psoriasin is highly up-regulated during a local mucosal infection, Candida albicans vulvovaginitis.

Psoriasin binds to β-glucan in the Candida albicans cell wall and thereby inhibits adhesion of the pathogen.

Binding of psoriasin to Candida albicans induces an immune response by mucosal epithelial cells.

Electronic supplementary material

The online version of this article (10.1007/s00109-018-1637-6) contains supplementary material, which is available to authorized users.

Radiotherapy for cervical cancer - impact on the vaginal epithelium and sexual function

BACKGROUND

Women who have been treated for cervical cancer have persistent changes in their sexual function, which result in considerable distress. The aim of this study was to investigate the morphology of the vaginal epithelium in cervical cancer survivors treated with radiotherapy and its correlation to serum levels of sex steroid hormones and sexual function.

MATERIAL AND METHODS

We included 34 patients treated for cervical cancer with radiotherapy and 37 healthy age-matched control women scheduled for benign gynecological surgery. After inspection and grading of vaginal atrophy, vaginal biopsies were taken. Epithelial structures were analyzed by measuring epithelial thickness as well as the number, height and width of the dermal papillae and the dermal papillae distance. Sex steroid hormone levels were analyzed and a questionnaire designed to assess sexual function was filled out.

RESULTS

In the cervical cancer survivors treated with radiotherapy, the vaginal epithelium volume was reduced compared to control women. Longer distance between the dermal papillae (p < .001) and a shorter distance from basal layer to epithelial surface (p < .05) were measured. Mucosal atrophy was observed in 91% of the survivors. There was no difference in serum estradiol between cancer survivors and control women, implying that the cancer survivors were sufficiently substituted. The epithelial thickness correlated to serum levels of estradiol. The cervical cancer survivors reported more physical sexual symptoms. The highest relative risk (RR) was found for insufficient vaginal lubrication (RR 12.6), vaginal inelasticity (RR 6.5), reduced genital swelling when sexually aroused (RR 5.9), and for reduction of vaginal length during intercourse (RR 3.9).

CONCLUSION

We found that cervical cancer treatment including radiotherapy is associated with vaginal epithelial atrophy and sexual dysfunction. To hamper the atrophic process affecting the sexual function, an early start of local estrogen after therapy might be of importance.

Radiotherapy-induced vaginal fibrosis in cervical cancer survivors

BACKGROUND

Cervical cancer survivors treated with radiotherapy report vaginal inelasticity and decreased lubrication that may affect their sexual health, but it is unknown which normal tissue reactions mediate these symptoms. The aim of this study was to investigate the morphology of the connective tissue of the vaginal wall in cervical cancer survivors treated with radiotherapy.

MATERIAL AND METHODS

We recruited 34 cervical cancer survivors treated with radiotherapy and 37 age-matched controls. Via clinical examination the degree of vaginal atrophy and pelvic fibrosis were estimated. We collected vaginal biopsies, which underwent morphometric analysis focused on elastin and collagen. Additionally, radiation dose at biopsy site were calculated and correlated to the clinical and morphological findings.

RESULTS

The survivors had marked morphological vaginal changes, most prominent in the survivors that had received the highest radiation dose at the biopsy site. Mucosal atrophy was observed in 91% and pelvic fibrosis in 97%. A shorter vagina was measured; 7.0 cm versus 10.3 cm in controls (p < 0.001). The area fraction of elastin was greater in survivors; 10.0% (range 5.8-12.9), compared with controls; 3.4% (range 1.8-5.8), p < 0.001. The survivors had signs of elastosis with thick aggregated elastin fibers irregularly scattered throughout the connective tissue, while the controls had elastin fibers in a thin sub-epithelial layer. The area fraction of high density collagen in the connective tissue was larger among the survivors (p < 0.001). The collagen with the highest density (fibrosis) was more common in the group of cancer survivors that had received external radiation.

CONCLUSIONS

We found drastic differences in the vaginal wall between the irradiated cervical cancer survivors and the controls, indicating that radiotherapy-induced vaginal symptoms are mediated by connective tissue fibrosis and elastosis. Our results also support that patients treated with external radiation have the highest risk of developing vaginal fibrosis with impairment of their sexual health.

Elevated nitric oxide in recurrent vulvovaginal candidiasis - association with clinical findings

INTRODUCTION

Recurrent vulvovaginal candidiasis is defined as having three to four episodes per year and causes substantial suffering. Little is known about the mechanisms leading to relapses in otherwise healthy women. Nitric oxide is part of the nonspecific host defense and is increased during inflammation. Nitric oxide levels were measured and the expression of inducible nitric oxide synthase was analyzed in the vagina during an acute episode of recurrent vulvovaginal candidiasis and after treatment with fluconazole.

MATERIAL AND METHODS

Twenty-eight women with symptoms of recurrent vulvovaginal candidiasis were enrolled together with 31 healthy controls. Nitric oxide was measured with an air-filled 25-mL silicon catheter balloon incubated in the vagina for five minutes and then analyzed by chemiluminescence technique. Vaginal biopsies were analyzed for the expression of inducible nitric oxide synthase. Symptoms and clinical findings were surveyed using a scoring system. The measurements and biopsies were repeated in patients after six weeks of fluconazole treatment.

RESULTS

Nitric oxide levels were increased during acute infection (median 352 ppb) compared with controls (median 6 ppb), p < 0.0001. The levels decreased after treatment (median 18 ppb) but were still higher than in controls. Increased expression of inducible nitric oxide synthase was observed in the epithelial basal layer in patients before and after treatment compared with controls. Before treatment, there were positive correlations between nitric oxide and symptom (r_s  = 0.644) and examination scores (r_s  = 0.677), p < 0.001.

CONCLUSIONS

Nitric oxide is significantly elevated in patients with recurrent vulvovaginal candidiasis during acute episodes of infection and decreases after antifungal treatment. The results illustrate the pronounced inflammatory response in recurrent vulvovaginal candidiasis correlating to symptoms of pain and discomfort.

A118G polymorphism in the μ-opioid receptor gene and levels of β-endorphin are associated with provoked vestibulodynia and pressure pain sensitivity

Background and aims

Provoked vestibulodynia (PVD) is the most common cause of dyspareunia among young women. The aetiology is largely unknown and treatment is often extensive and longstanding with varying outcomes. Patients display general pain hypersensitivity and there are correlations with other chronic pain syndromes such as fibromyalgia later in life. The A118G polymorphism in the μ-opioid receptor (OPRM1) gene influences endogenous pain regulation and pain sensitivity, but has not been studied in this patient group before. We aimed to investigate a possible association between A118G polymorphism and PVD, with correlation to plasma levels of β-endorphin, and to explore relationships between this polymorphism and pain sensitivity among women with PVD and healthy controls.

Methods

This case-control study included 98 women with PVD and 103 controls. Participants filled out study-specific questionnaires and underwent quantitative sensory testing of pressure pain thresholds on the arm, leg and in the vestibular area. Levels of β-endorphin were analyzed by radioimmunoassay using the EURIA-beta-endorphin kit, and the A118G single-nucleotide polymorphism (SNP; rs1799971) in the OPRM1 gene was analyzed using the TaqMan SNP genotyping assay.

Results

The 118G allele was more common in controls (44%) than in patients (30%) (p = 0.042). The odds ratio of having PVD was 1.8 in participants carrying the 118A allele compared to participants hetero- or homozygous for the 118G allele (OR = 1.846, CI: 1.03-3.31, p = 0.039). Pressure pain thresholds on the leg were higher for participants carrying the 118G allele (mean 480 kPa, SD 167.5) than for those carrying the 118A allele (mean 419, SD 150.4, p = 0.008). Levels of β-endorphin were higher in patients (mean 17.9 fmol/ml, SD 4.71) than in controls (mean 15.8 fmol/ml, SD 4.03) (p < 0.001).

Conclusion

We found an association between the A118G polymorphism in the OPRM1 gene and an increased risk of PVD and increased pain sensitivity among participants carrying the 118A allele. PVD patients were more sensitive to pressure pain and had higher levels of plasma β-endorphin than controls. The results indicate that differences in endogenous pain modulation involving the opioid system could contribute to the pathophysiology of PVD and the general pain hypersensitivity seen in these women.

Implications

The data support the conceptualization of PVD as part of a general pain disorder with a possible genetic predisposition. The age of onset of PVD is usually between 18 and 25 years and already at this age general pain hypersensitivity is present but rarely causing disability. We believe that early recognition and treatment, with the risk of further development of chronic pain taken into consideration, might prevent future aggravated pain problems in this patient group.

Standard operating procedures for female genital sexual pain

INTRODUCTION

Female genital sexual pain (GSP) is a common, distressing complaint in women of all ages that is underrecognized and undertreated. Definitions and terminology for female GSP are currently being debated. While some authors have suggested that GSP is not per se a sexual dysfunction, but rather a localized genial pain syndrome, others adhere to using clearly sexually related terms such as dyspareunia and vaginismus.

AIM

The aims of this brief review are to present definitions of the different types of female GSP. Their etiology, incidence, prevalence, and comorbidity with somatic and psychological disorders are highlighted, and different somatic and psychological assessment and treatment modalities are discussed.

METHODS

The Standard Operating Procedures (SOP) committee was composed of a chair and five additional experts. No corporate funding or remuneration was received. The authors agreed to survey relevant databases, journal articles and utilize their own clinical experience. Consensus was guided by systematic discussions by e-mail communications. MAIN OUTCOME/RESULTS: There is a clear lack of epidemiological data defining female GSP disorders and a lack of evidence supporting therapeutic interventions. However, this international expert group will recommend guidelines for management of female GSP.

CONCLUSIONS

GSP disorders are complex. It is recommended that their evaluation and treatment are performed through comprehensive somato-psychological multidisciplinary approach.

GCH1-polymorphism and pain sensitivity among women with provoked vestibulodynia

Background

Provoked vestibulodynia (PVD) is a pain disorder localized in the vestibular mucosa. It is the most common cause of dyspareunia among young women and it is associated with general pain hypersensitivity and other chronic pain conditions. Polymorphism in the guanosine triphosphate cyclohydrolase (GCH1) gene has been found to influence general pain sensitivity and the risk of developing a longstanding pain condition. The aim of this study was to investigate GCH1-polymorphism in women with PVD and healthy controls, in correlation to pain sensitivity.

Results

We found no correlation between the previously defined pain-protective GCH1-SNP combination and the diagnosis of PVD. Nor any correlation with pain sensitivity measured as pressure pain thresholds on the arm, leg and in the vestibule, coital pain scored on a visual analog scale and prevalence of other bodily pain conditions among women with PVD (n = 98) and healthy controls (n = 102). However, among patients with current treatment (n = 36), there was a significant interaction effect of GCH1-gene polymorphism and hormonal contraceptive (HC) therapy on coital pain (p = 0.04) as well as on pressure pain thresholds on the arm (p = 0.04). PVD patients carrying the specified SNP combination and using HCs had higher pain sensitivity compared to non-carriers. In non-HC-users, carriers had lower pain sensitivity.

Conclusions

The results of this study gave no support to the hypothesis that polymorphism in the GCH1-gene contributes to the etiology of PVD. However, among patients currently receiving treatment an interaction effect of the defined SNP combination and use of hormonal contraceptives on pain sensitivity was found. This finding offers a possible explanation to the clinically known fact that some PVD patients improve after cessation of hormonal contraceptives, indicating that PVD patients carrying the defined SNP combination of GCH1 would benefit from this intervention.

Chronic stress in women with localised provoked vulvodynia

BACKGROUND

Localised provoked vulvodynia (former vulvar vestibulitis syndrome) is the most common cause of superficial dyspareunia among young women. In a clinical setting, it is obvious that many women with localised provoked vulvodynia show signs of chronic stress. The objective of this study was to compare chronic stress in a group of women with localised provoked vulvodynia, referred to the vulvar unit at the Division of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden with control women of the same age and educational level, using two independent methods.

METHODS

Forty-three women with localised provoked vulvodynia and 35 healthy control women underwent a gynecological examination, filled in a health questionnaire, and self-collected saliva for analysis of cortisol at awakening and after 15, 30 and 45 min (morning awakening cortisol). Thirty-three patients and 28 controls completed a stress questionnaire.

RESULTS

Morning awakening cortisol was blunted in women with localised provoked vulvodynia (p < 0.05), indicating chronic stress. The stress questionnaire showed more signs of burnout (p < 0.005), and emotional (p < 0.05) and bodily symptoms of stress (p < 0.005) in women with localised provoked vulvodynia compared with control subjects (students t-test).

CONCLUSION

More women with localised provoked vulvodynia showed blunted morning awakening cortisol and reported more symptoms of stress compared with healthy control women of the same age.

Combined physical and psychosexual therapy for provoked vestibulodynia-an evaluation of a multidisciplinary treatment model

Our objective is to standardize and evaluate a combined physical and psychosexual therapy for women with provoked vestibulodynia. Twenty-four patients underwent the treatment program. Sessions with a psychosexual counselor included issues on sexual functioning, psychological adjustments, and stress elimination. Exercises for mucosal desensitization and reestablishment of pelvic floor function were supervised by a midwife. A questionnaire was used for evaluation at a minimum of 6 months after the treatment. The mean number of appointments to the counselor was 12 (4-24) and 15 (9-26) to the midwife during a mean period of 53 weeks (19-92). Nineteen women (79%) considered themselves to be cured or having greatly improved. Intercourse frequency was increased (p = 0.001) and coital pain was reduced (p = 0.02) after completing the treatment. Improvements in sexual functioning and coping strategies for psychological impairment and stress were reported. Women with provoked vestibulodynia benefit from a multidisciplinary treatment model including desensitization of the vestibular mucosa, rehabilitation of the pelvic floor, and psychosexual adjustments.

Surgery for localized, provoked vestibulodynia: a long-term follow-up study

OBJECTIVE

To evaluate the long-term results of vestibulectomy in women with localized, provoked vestibulodynia.

STUDY DESIGN

A retrospective questionnaire survey was filled out by 67 Swedish women who underwent surgery for localized, provoked vestibulodynia during 1992-2003. The questionnaire was completed a minimum of 12 months after the operation. Coital pain, quality of sexual life and psychologic well-being were evaluated.

RESULTS

The mean age at the time of surgery was 27 years (18-56) and the median follow-up time 41 months (12-120). Coital pain, rated with Visual Analogue Scales (VAS(neg)) (0-10), was 8.0 (median) before surgery, 5.0 (p < 0.001) 6 months after surgery and 2.0 (p < 0.001) at follow-up. Quality of sexual life, using VAS(pos) (10-0), was 6.5 (median) before dyspareunia, 0.5 (p < 0.001) prior to surgery and 6.5 (p < 0.001) at followup. Complete or major improvement was reported by 56% of women with secondary vestibulodynia and 17% of women with primary vestibulodynia (p = 0.03). Improved psychologic well-being was reported by 79%.

CONCLUSION

Women with secondary localized provoked vestibulodynia will often benefit from surgery when other treatments fail. Surgical outcome should include both pain relief and psychosexual well-being. In this study women with primary vestibulodynia were less likely to benefit from surgery.

Steroid receptor expression in the vulvar vestibular mucosa — effects of oral contraceptives and menstrual cycle

BACKGROUND

The objective was to evaluate the influence of combined oral contraceptives (COC) and of the menstrual cycle on the steroid receptor expression in the vulvar vestibular mucosa of healthy women.

STUDY DESIGN

Forty-five healthy women (20 with COC and 25 without) were included. Vestibular biopsies were obtained during the menstrual cycle. Estrogen receptors (ER) alpha and beta, progesterone receptors (PR) A and B, glucocorticoid receptor and androgen receptor as well as the proliferation marker Ki67 were analyzed using immunohistochemistry followed by computerized image analysis.

RESULTS

The vestibular stromal tissue of women using COC expressed more ERbeta (p=.024) than that of women without COC. In the follicular phase, PRB was more abundant in the stromal tissue than in the luteal phase (p=.01).

CONCLUSIONS

ERbeta is more abundant in the vulvar vestibular mucosa of women using COC than in that of women without COC. There is a cyclic variation in PRB in the vestibular mucosa in healthy women without COC.

The vulval vestibular mucosa?morphological effects of oral contraceptives and menstrual cycle

BACKGROUND

An erythematous and hypersensitive vestibular mucosa has been observed during the use of combined oral contraceptives (COC). Hormonal effects on the vestibular morphology have not been studied.

OBJECTIVES

Our aim was to evaluate the morphology of the vulval vestibular mucosa during the influence of COC and during the menstrual cycle.

METHODS

Forty-five healthy women (20 using COC and 25 not using COC) were included. A 6-mm punch biopsy was obtained from the right posterior vestibule on days 7-11 of the menstrual cycle. A corresponding biopsy was taken 2 weeks later in 16 women without COC. The epithelial morphology was estimated by measuring interdermal papilla distance, dermal papilla to surface, from basal layer to surface and width of dermal papillae. A histopathological assessment was made.

RESULTS

The vulval vestibular mucosa of women using COC displayed a larger distance between the dermal papillae (P = 0.04) and a larger space from the dermal papillae to the epithelial surface (P = 0.03) compared with controls in the follicular phase. Women without COC displayed a larger interdermal papilla distance in the luteal phase compared with the follicular phase, P = 0.02. Histopathology showed more superficial blood vessels in the COC users (P < 0.01).

CONCLUSIONS

The vulval vestibular mucosa of women with COC display an altered morphological pattern with shallow and sparse dermal papillae compared with the follicular phase. Similar findings are seen in women without COC during the luteal phase which indicate a gestagenic effect on the mucosa. Associations between the morphological pattern and changes in mucosal mechanical sensitivity require further studies.

The Result of Treatment on Vestibular and General Pain Thresholds in Women With Provoked Vestibulodynia

OBJECTIVE

To correlate changes in vestibular pain thresholds to general pain thresholds in a subgroup of women with provoked vestibulodynia taking part in a treatment study.

METHODS

Thirty-five women with provoked vestibulodynia were randomized to 4 months' treatment with either electromyographic biofeedback (n=17) or topical lidocaine (n=18). Vestibular and general pressure pain thresholds (PPTs) were measured and the health survey Short Form-36 (SF-36) was filled out before treatment and at a 6-month follow-up. Subjective treatment outcome and bodily pain were analyzed. Thirty healthy women of the same age served as controls for general PPTs and SF-36.

RESULTS

No differences in outcome measures were observed between the 2 treatments. Vestibular pain thresholds increased from median 30 g before to 70 g after treatment in the anterior vestibule (P<0.001) and from median 20 to 30 g in the posterior vestibule (P<0.001). PPTs on the leg and arm were lower in the patients as compared with controls both before and at the 6-month follow-up. Patients reporting total cure were 3/35; 25/35 were improved. The number of patients who frequently reported of other bodily pain was reduced after the treatment. The patients had lower scores for SF-36 (General Health, Vitality) before treatment, which was restored at the 6-month follow-up.

DISCUSSION

Treating provoked vestibulodynia by either topical lidocaine or electromyographic biofeedback increased vestibular pain thresholds, reduced dyspareunia, and improved bodily pain. The patients showed a general hypersensitivity to pressure pain compared with controls and in this study the hypersensitivity did not seem to be affected by treating the superficial dyspareunia.

Evidence of diffuse noxious inhibitory controls (DNIC) elicited by cold noxious stimulation in patients with provoked vestibulodynia

Provoked vestibulodynia is a common cause of superficial dyspareunia in young women. Recent evidence has pointed out the importance of studying endogenous pain modulation in these women. An impairment of diffuse noxious inhibitory controls (DNIC) has been suggested in chronic pain conditions with a female predominance such as fibromyalgia and temporomandibular disorder. Our aim was to examine whether patients with provoked vestibulodynia and healthy women with or without combined oral contraceptives (COC) display a DNIC response to cold noxious stimulation. Twenty patients with provoked vestibulodynia not using COC, 20 healthy women on COC and 20 healthy women without COC were included and tested days 7-11 of their menstrual cycle. Pressure pain thresholds (PPTs) and pain ratings using VAS were measured on the arm and leg before and during a cold pressor test. A socio-medical questionnaire, the Hospital and Anxiety Depression Scale and the Short Form-36 were completed. The majority of the subjects in all three study groups significantly increased their PPTs during cold noxious stimulation indicating a DNIC response. The patients displayed lower PPTs compared to the healthy women. Depression, anxiety and bodily pain were more often reported by the patients. No differences related to the intake of COC were observed between the healthy women. In conclusion, women with provoked vestibulodynia as well as healthy women irrespective of COC status display a DNIC response indicating an endogenous pain inhibition. However, the results imply a systemic hypersensitivity in women with vestibulodynia with low general pain thresholds as compared to healthy women.

EMG biofeedback versus topical lidocaine gel: a randomized study for the treatment of women with vulvar vestibulitis

BACKGROUND

To evaluate the efficacy of electromyographic biofeedback and topical lidocaine treatment for women with vulvar vestibulitis.

METHODS

A prospective randomized study where 46 women with vulvar vestibulitis were randomized to receive either electromyographic biofeedback or topical lidocaine treatment for four months. Assessments with vulvar pressure pain thresholds and questionnaires regarding quality of life, psychosocial adjustments, and sexual functioning were made before treatment, after treatment, and at six- and 12-month follow-ups. Nonparametric statistical methods were used to analyze differences in outcomes.

RESULTS

Nine women (9/46) dropped out during the treatment period. Both treatments showed significantly improved values for vestibular pressure pain thresholds, quality of life measurements, and sexual functioning at the 12-month follow-up. No differences were found between the two treatment groups. No severe side effects were reported.

CONCLUSIONS

Four months' treatment with electromyographic biofeedback and topical lidocaine gave statistically significant improvements on vestibular pain measurements, sexual functioning, and psychosocial adjustments at the 12-month follow-up. No differences in outcome between the two treatments were observed but a larger sample may be needed to obtain significance. The treatments were well tolerated but the compliance to the electromyographic biofeedback training program was low. A combination of both treatments could potentially benefit many women with vulvar vestibulitis.

Decreased mechanical pain threshold in the vestibular mucosa of women using oral contraceptives: a contributing factor in vulvar vestibulitis?

OBJECTIVE

To analyze possible differences in somatosensory perception in the vestibular mucosa in healthy women associated with the use of oral contraceptives.

STUDY DESIGN

Quantitative sensory tests were performed on the vestibular mucosa in 39 healthy women. Twenty women were using oral contraceptives containing 30-40 microg ethinyl estradiol combined with various progestins; 19 women with regular menstrual periods not using oral contraceptives served as controls. The testing included mechanical and heat pain thresholds and detection thresholds of warmth and cold in the anterior and posterior part of the vestibule.

RESULTS

Significant lower mechanical pain thresholds were observed in both areas tested in women using oral contraceptives. The most sensitive area was the posterior vestibule in the group using oral contraceptives with a mechanical pain threshold of 72 +/- 10 ( +/-SEM) mN as compared to 161 +/- 3 mN (p < 0.01), in the controls. The result of the thermotest showed no significant differences between the groups.

CONCLUSION

Oral contraceptives may induce increased sensitivity in the vestibular mucosa in healthy women and might be one contributingfactor in the development of vulvar vestibulitis.

A computerised, unbiased method for epithelial measurement

OBJECTIVE

To develop and evaluate a standardised method for unbiased measurements of epithelial thickness taking the variability of the dermal papillae in consideration.

METHODS

A computer-assisted measurement program suitable for haematoxylin and eosin routine stained specimens has been developed.

RESULTS

The developed program was designed to measure four different distance parameters, taking the number, height and width of dermal papillae into account. The measurement program gave very accurate results compared with manual measurements. The measurement results can be presented as tables or star graphs, and the results can be further processed by multivariate analysis.

CONCLUSION

The computer-assisted measurement program is considered to be a valuable and reliable tool for measurements of epithelial thickness, irrespectively of the variability of the epithelial morphology. Since length, size and number of the papillae may change with certain pathological conditions, age and also under hormonal influence, this method can be a helpful diagnostic tool.

Increased blood flow and erythema in the posterior vestibular mucosa in vulvar vestibulitis(1)

OBJECTIVE

To evaluate vascular changes as a possible underlying cause of mucosal erythema in women with vulvar vestibulitis.

METHODS

Laser Doppler perfusion imaging was used to map the superficial blood flow in the vestibular mucosa in 20 women with vestibulitis and in 21 healthy control subjects. A possible correlation between perfusion values and graded erythema (1-5) around the vaginal introitus was analyzed. Changes in microvascular density in the posterior part of the mucosa were investigated in sections from ten patients and ten controls by a computer-assisted image-processing program. Induced vasoconstriction of terminal arterioles in the same posterior area was also studied.

RESULTS

Significant increases in perfusion values were registered in the posterior parts of the vestibular mucosa in patients compared with controls. The highest blood flow was registered in the posterior fourchette. The most pronounced erythema was also located in the posterior vestibule in the patients. However, there was no significant correlation between perfusion values and degree of erythema in the same individual. The microvascular density or the ability of vestibular arterioles to constrict did not differ between patients and controls.

CONCLUSION

Women with vestibulitis have an increased superficial blood flow and erythema in the posterior parts of the vestibular mucosa. The increased perfusion, most probably caused by a neurogenic vasodilatation contributes to, but does not fully explain the erythema. Atrophic changes of the surface epithelium should also be considered in the evaluation of an erythema.

Psychophysical evidence of nociceptor sensitization in vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is a long lasting disorder of superficial dyspareunia in young women. Quantitative sensory testing, including mechanical and temperature pain thresholds and warm/cold difference limen (WCL), was performed in the vestibular mucosa in 22 women (mean age 25.0 years) with vestibulitis and 20 control subjects (mean age 25.6 years). The tests were carried out on days 7-11 of the menstrual cycle. Patients had allodynia to mechanical testing with von Frey filaments, 14.3+/-3.1mN in the symptomatic posterior area as compared with 158+/-33.5mN in healthy subjects, P<0.0001. The pain threshold to heat was 38.6+/-0.6 degrees C in patients and 43.8+/-0.8 degrees C in controls, P<0.0001. In addition, pain threshold to cold was 21.6+/-1.2 degrees C in patients whereas cooling down to 6 degrees C was usually not painful in controls. WCL was 4.9+/-0.5 degrees C in patients and 9.6+/-1.5 degrees C in healthy subjects, P<0.01. The results are compatible with the hypothesis that patients with VVS have an increased innervation and/or sensitization of thermoreceptors and nociceptors in their vestibular mucosa.

The expression of cyclooxygenase 2 and inducible nitric oxide synthase indicates no active inflammation in vulvar vestibulitis

BACKGROUND

Although women with vulvar vestibulitis syndrome have principal symptoms of inflammation such as local erythema and pain in the mucosa around the vaginal introitus, it is not clear if vestibulitis is an inflammatory condition. Cyclooxygenase 2 and inducible nitric oxide synthase are known to be upregulated during inflammation. The aim of the present study was to analyze the expression of these enzymes in the vestibular mucosa in order to evaluate the inflammatory activity in the tissue.

METHODS

Ten women fulfilling Friedrich's criteria of vulvar vestibulitis syndrome and ten control subjects were included in the study. Punch biopsies were obtained from the vestibular mucosa for analysis of cyclooxygenas 2 and inducible nitric oxide synthase, using indirect immunohistochemistry and Western dot-blot analyses.

RESULTS

Both methods used showed low expression of cyclooxygenas 2 and inducible nitric oxide synthase in the vestibular mucosa of all women. There was no difference observed between the groups.

CONCLUSIONS

There is a low expression of the inflammatory markers cyclooxygenas 2 and inducible nitric oxide synthase in the vestibular mucosa of women with vulvar vestibulitis syndrome as well as in healthy control subjects. The results indicate no active inflammation present and imply that topical corticosteroids in the treatment of vulvar vestibulitis are unfounded.

[Vulvar vestibulitis is a condition with diffuse etiology]

Vestibulum vulvae is covered by a sensitive mucosa of endodermal origin. The pain syndrome "vulvar vestibulitis", which is frequently occurring in young women, gives rise to intensive pain during sexual intercourse. The diagnosis requires at least six months duration of provoked pain and the presence of red areas in the vestibulum, which are intensely painful to the touch. There is an increased intraepithelial innervation but no active inflammation. The etiology of vulvar vestibulitis is probably multifactorial. Possible trigger mechanisms include repeated use of antibiotics and local treatment of Candida and HPV infections in combination with the use of hormonal contraceptives, frequent use of local substances that may be irritative, lack of arousal, vaginismus and tense pelvic floor muscles. Spontaneous recovery is possible if all treatment is suspended. Other regimens include biofeedback, psychotherapy, tricyclic antidepressants and surgery. There is a 80 per cent success rate after surgery in carefully selected patients.

Increased intraepithelial innervation in women with vulvar vestibulitis syndrome

Women with vulvar vestibulitis syndrome (VVS) suffer from severe pain and discomfort in the area around the introitus at almost any stimulus that causes pressure within the vestibule. In spite of the severe sensory symptoms present in these women, the influence of the peripheral nerves in the vulvar vestibulum has not been clarified before. In this study the nerve supply in the vestibular mucosa in women with VVS and in healthy women free from vulvar symptoms has been revealed by PGP 9.5 immunohistochemistry. The results show a significant increase in the number of intraepithelial nerve endings in women with VVS, indicating an alteration in the nerve supply in the afflicted area.

Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome

Women with vulvar vestibulitis syndrome (VVS) have a distinct burning pain provoked by almost any stimuli in the area around the vaginal introitus. In a previous study we observed an increased number of intraepithelial free nerve endings in women with VVS. The aim of the present study was to neurochemically characterize the superficial nerves in the vulvar vestibular mucosa of women with VVS. Immunohistochemical methods were used to detect neuropeptides normally found in various types of nerve fibers. Calcitonin gene-related peptide, which is known to exist in nociceptive afferent nerves, was the only neuropeptide detected in the superficial nerves of the vestibular mucosa. These findings confirm our previous theory that the free nerve endings within the epithelium are nociceptors.