"Time is on my side". Disease trajectory of vulvodynia: a systematic review with a narrative synthesis

PURPOSE

The aim of this systematic review was to shed light on the disease-trajectory of vulvodynia and identify potential risk factors which may affect such trajectory.

METHODS

We searched Pubmed to identify articles providing evidence on vulvodynia trajectory (i.e., remission, relapse or persistence rates) with a minimum follow-up of 2 years. A narrative approach was used for data synthesis.

RESULTS

Four articles were included (total participants: 741 women with vulvodynia; 634 controls). At a 2-year follow-up, 50.6% of women reported remission, remission with relapse was observed in 39.7% and persistence throughout time occurred in 9.6%. A decrease in pain was observed in 71.1% of patients at a 7-year follow-up. Mean pain scores and depressive symptoms resulted lower at 2-year follow-up, whereas sexual function and satisfaction were increased. Factors associated with remission of vulvodynia were greater couple cohesion, decreased reporting of pain after intercourse and lower levels of worst pain. Risk factors for symptom persistence included marriage, more severe pain ratings, depression, pain with partner touch, interstitial cystitis, pain with oral sex, fibromyalgia, older age and anxiety. Recurrence was associated with: longer duration of pain, more severe ratings of the worst pain ever and pain described as provoked.

CONCLUSIONS

Symptoms of vulvodynia seem to improve over time, regardless of treatment. This finding contains a key message for patients and their physicians, considering the deleterious consequences of vulvodynia on women's lives.

Topical estrogens for the treatment of superficial dyspareunia related to genitourinary syndrome of menopause in women with a history of endometriosis: A clinical dilemma

Estrogen withdrawal, which occurs with the cessation of ovulation, causes genitourinary syndrome of menopause in up to 50-85% of women. Symptoms may profoundly impact quality of life and sexual function, interfering with enjoyment of sex in up to three out of four individuals. Topical estrogens have been found to provide symptom relief with minimal systemic absorption and appear to be superior to systemic therapy as what regards genitourinary symptoms. However, conclusive data on their appropriateness in postmenopausal women with a history of endometriosis is not available and the hypothesis that exogenous estrogen stimulation may reactivate endometriotic foci or even promote their malignant transformation is still open. On the other hand, endometriosis affects around 10% of premenopausal women, many of which may be exposed to an acute hypoestrogenic depletion even before spontaneous menopause occurs. This considered, excluding on principle patients with a history of endometriosis from first-line treatment for vulvovaginal atrophy would mean excluding a considerable percentage of the population from adequate care. More robust evidence is urgently needed in these regards. Meanwhile, it would appear reasonable to tailor the prescription of topical hormones in these patients, taking into account the entity of symptoms and the impact such symptoms have on patients' quality of life, as well as the form of endometriosis and the possible risks hormonal may entail. Moreover, the application of estrogens on the vulva instead of the vagina could be efficacious, while outweighing the possible biological cost of hormonal treatment in women with a history of endometriosis.

Impact of a multiparameter, ultrasound-based triage on surgical management of adnexal masses

OBJECTIVE

To prospectively evaluate the accuracy of a multiparameter, ultrasound-based triage and its impact on surgical management of adnexal masses.

METHODS

Masses evaluated as normal according to Ferrazzi's sonographic morphological score were considered as being at low risk of malignancy and eligible for laparoscopic treatment without further evaluation. Masses evaluated as abnormal, but without additional risk factors such as ascites, diameter > or = 10 cm, bilaterality, immobility, resistance index < or = 0.6 and serum CA 125 > 35 IU/mL were considered at moderate risk and eligible for laparoscopic evaluation and treatment. Masses with abnormal morphological score and any of these additional risk factors were considered at high risk and treated by laparotomy. The results of pathological examination were obtained for each mass.

RESULTS

Two hundred and four (87%) masses were benign and 30 (13%) were malignant. Among 182 low-risk, 19 moderate-risk and 33 high-risk masses, the odds of malignancy were 1 : 90, 1 : 18 and 4.5 : 1, respectively. To calculate the diagnostic accuracy of this algorithm, low- and moderate-risk groups were considered together: the sensitivity was 90%, specificity 97%, positive predictive value 82% and negative predictive value 99%. The new algorithm was significantly more accurate than was morphological score alone (P = 0.0002). Ninety-six percent of benign masses were treated by laparoscopy. All three patients with malignant masses that were incorrectly assigned to laparoscopy underwent laparoscopic adnexectomy and frozen section.

CONCLUSIONS

The accuracy of this new algorithm was higher than that of the sonographic morphological scoring system alone. In the present series, it allowed the treatment by laparoscopy of 96% of benign adnexal masses without mismanagement of any cases of ovarian cancer.

Adsorption of imidazolinone herbicides on smectite-humic acid and smectite-ferrihydrite associations

Adsorption of imazapyr (IMZ), imazethapyr (IMZT), and imazaquin (IMZQ) was studied on two smectite-humic acid and two smectite-ferrihydrite binary systems prepared by treating a Wyoming smectite with a humic acid extracted from soil (4 and 8% w/w of the smectite) and with just-precipitated synthetic ferrihydrite (8 and 16% w/w of the smectite). Adsorption of the three herbicides on the smectite was not measurable at pH >4.5, presumably because of negative charges on the surface of the smectite. Adsorption on the smectite-humic acid systems was also not measurable, presumably because of negative charges on the surface, despite the high affinity of the three herbicides for humic acid, the adsorption order of which was IMZ < IMZT << IMZQ. Adsorption decreased in the order IMZ < IMZT < IMZQ on the smectite-ferrihydrite systems and IMZQ < IMZT < IMZ on ferrihydrite, although here the differences were small. These results show that even though pure smectite cannot adsorb herbicides, it modifies the adsorption capacity of ferrihydrite. The mutual interaction of active phases such as humic acid, ferrihydrite, and smectite alters the characteristics of the resulting surface and hence the adsorption process. Investigations of herbicide adsorption have been seen to produce more reliable results if conducted on polyphasic systems rather than on single soil components.

Role of ferrihydrite in adsorption of three imidazolinone herbicides

Adsorption of the imidazolinone herbicides imazapyr, imazethapyr, and imazaquin on synthetic ferrihydrites, either freeze-dried or not-freeze-dried, has been studied. The synthetic ferrihydrites were characterized by X-ray diffraction, scanning electron micrographs, and specific area determination. On each ferrihydrite, adsorption was found to be strongly dependent on pH. The highest extent of adsorption took place at pH values close to the pK(a) of the carboxylic group of the herbicides. No adsorption was observed at pH > 8. The freeze-drying process reduced the adsorptive capacity of the ferrihydrite by formation of larger aggregates provoking a decrease of the surface area. The chemical differences between the herbicides did not strongly affect the adsorption process of the herbicides. However, imazaquin was more adsorbed than the other two herbicides, in particular at pH close to its pK(a).

Adsorption of imidazolinone herbicides on ferrihydrite-humic acid associations

Adsorption of the imidazolinone herbicides imazapyr, imazethapyr and imazaquin was studied on two binary systems (ferrihydrite-humic acid) prepared by treating ferrihydrite (Fh) immediately after its precipitation with a soil humic acid (HA) at different loadings (4% and 8% HA content), and on a blank ferrihydrite sample prepared in the same way, but without HA addition. Imidazolinone adsorption on pure Fh and on the 4% Fh-HA decreased with increasing of the herbicide hydrophobicity (imazaquin<imazethapyr<imazapyr), whereas on the 8% Fh-HA system the order of adsorption was nearly the same, indicating that higher amounts of HA on Fh increase the hydrophobicity of the surface and thus increases its affinity for the herbicides, specially for imazaquin. Adsorption was also enhanced by low pH values and slight changes in pH enhanced the contribution of each component in adsorption. Both the nature of the surface exposed and its ability to interact with herbicides are greatly altered by the mutual interaction of Fh and HA. The results show that albeit artificial polyphasic associations are more representative of the real situation than single model components and are thus better indicators of the behaviour of a given herbicide in the soil.