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.

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.