Dyspareunia Symptoms Research Articles

Features of the clinical course of endometriosis in papillomavirus infection

Background: To date, the etiology and pathogenesis of endometriosis are still unclear and are determined by a number of factors (genetic, immunological and endocrine), including microbiological ones. Aim: The aim of this study was to characterize the clinical course of endometriosis in papillomavirus infection. Materials and methods: This retrospective analysis included 185 outpatient records of patients with genital endometriosis and comprised complaints, anamnesis data, objective examination, cytological and molecular biological examination results. All patients were divided into two study groups. Group 1 (main) consisted of patients with endometriosis and human papillomavirus (n = 56), and group 2 (comparison) included patients with endometriosis and no human papillomavirus (n = 129). Results: The frequency of human papillomavirus detection among patients with endometriosis was 30.3 (95% confidence interval 24–38)%. The most frequent types detected were 31 (20%), 16 (18%), 18 (18%), 56 (16%), and 53 (13%). The conclusion of cervical cytological examination: in group 1 was the following 54/56 patients had negative for intraepithelial lesion or malignancy (NILM) and 2/56 patients had low grade squamous intraepithelial lesion (LSIL), all patients in group 2 had NILM. The average duration of endometriosis was 8.2 ± 5.0 years for patients in group 1 and 9.4 ± 5.9 years for patients in group 2 (p = 0.15). We found differences between the study groups with respect to the following parameters: the average age of sexual debut was 17.82 ± 1.47 years and 18.53 ± 1.43 years for groups 1 and 2, respectively. Dyspareunia occurred in 77 (95% confidence interval 63–87)% of women in Groups 1 and in 42 (95% confidence interval 33–51)% in groups 2 (p 0.001). The average pain severity score according to the visual analogue scale was 6.7 ± 2.4 and 5.9 ± 2.8 points, respectively (p = 0.039). In group 1, impaired vaginal microbiocenosis was more common. Conclusions: Human papillomavirus was detected in every third woman with endometriosis, most often in genotypes of high carcinogenic risk. Among the features of the clinical course of endometriosis in the presence of human papillomavirus, more pronounced pain syndrome and symptoms of dyspareunia were noted. In the group of women with human papillomavirus, impaired vaginal microbiocenosis was more often observed.

Predictors of anxiety in endometriosis patients.

To evaluate the main factors influencing anxiety in endometriosis patients presenting to an endometriosis centre in Germany. One hundred and eighty-two patients were asked to complete the German version of the STAI (state anxiety and trait anxiety) questionnaire prior to examination for diagnosis and treatment of pelvic pain or suspected endometriosis. Typical endometriosis symptoms, main complaints, operations, type of endometriosis and planned treatment were analyzed as influencing factors of anxiety in endometriosis patients. We performed linear multiple regression analyses using the forward stepwise method to test which characteristics associated with endometriosis symptoms were associated with trait anxiety and state anxiety. Analysis of the STAI results showed that higher levels of trait anxiety were found in patients with ovarian endometriosis: t (177) = 3.06, p = 0.003 and in patients with symptoms of dyspareunia: t (177) = 2.36, p < 0.020). On the other hand, patients with recurrent endometriosis showed lower levels of trait anxiety: t (177) = -2.39, p = 0.018. Significantly higher levels of state anxiety were found in patients with persistent endometriosis: t (177) = -2.45, p = 0.015 and in women with endometriosis who were indicated for surgical therapy: t (177) = 3.89, p < 0.001. We were able to show that higher levels of ongoing anxiety in endometriosis patients are associated with dyspareunia and ovarian endometriosis, which may have a negative impact on partnership and desire to have children. On the other hand, patients with persistent endometriosis or a type of disease that requires surgery have higher levels of immediate situational anxiety.

Impact of endometriosis on the quality of sexual life of women of reproductive age in Poland

Aim. The aim of this study is to demonstrate the impact of endometriosis on the quality of sexual life of women in Poland, through a comparative analysis of a population of healthy women and those struggling with the condition. Methods. The study was conducted using the validated FSFI questionnaire and the author’s supplementary questions. Information about the survey was made available on social networks and groups for women with endometriosis, as well as to healthy women constituting a control group. The CAWI technique was used in the study. The survey consisted of questions divided into mod- ules: metric data, having endometriosis and previous treatment, sexuality before and after possible treatment, and for healthy women - current assessment of the quality of sexual life. Results. Endometriosis negatively affects the quality of sexual life of women of reproductive age in Poland. Decreased quality of sexual life occurring in women with endometriosis indicates the presence of clinically significant sexual dysfunctions. Dyspareunia (a type of sexual dysfunction that manifests itself as pain during intercourse (Lew-Starowicz, Lew-Starowicz, &amp; Skrzypulec-Plinta, 2020)) is signifi- cantly more common in women with endometriosis than in healthy women in Poland. 69 percentage points more women indicate the presence of dyspareunia when suffering from endometriosis compared to healthy women. Treatment reduces pain symptoms in women suffering from endometriosis. 24 per- centage points more women show no symptoms of dyspareunia after treatment, compared to women before treatment. The presence of endometriosis does not significantly affect women’s sense of sexual at- tractiveness. Women with endometriosis, despite the presence of pain, engage in sexual activity as often as healthy women. Treatment of endometriosis, both pharmacological and surgical, increases the quality of sexual life of women of reproductive age in Poland.

Antioxidant Agent to Improve Endometriosis Related Pain (Dysmenorrhea, Dyspareunia, Pelvic Pain): A Systematic Review and Meta-Analysis

Introduction: Endometriosis is a chronic condition characterized by the presence of endometrial-like tissue outside the uterus, which causes estrogen-induced inflammation. Pelvic severe pain, dysmenorrhea, and dyspareunia are known as the most common symptoms in endometriosis patients. Antioxidants can help alleviate endometriosis-related pain. However, the mechanism is not fully understood. A study is needed to elucidate the inherent potential of an antioxidant in women with endometriosis. Material and Methods: The literature search was conducted in two databases. The outcome of interest is to measure mean changes based on pain severity using the VAS score in endometriosis-related pain, including dysmenorrhea, pelvic pain, and dyspareunia. Some of the antioxidant agents formed in this study are vitamin D, vitamin C, vitamin E, livergol (silymarin), garlic tablets, resveratrol, and melatonin compared to placebo. Meta-analysis was done using RevMan 5.4 using mean change from baseline data with their 95% confidence intervals (CI) provided. Results: Twelve studies meeting the inclusion criteria were considered relevant for assessing the potencies of antioxidants in endometriosis patients (n=695). The antioxidant group had significantly better pelvic pain improvement (MD: -2.21, 95%CI: -3.40 to -1.03, p=0.0003), reduction in dyspareunia symptoms (MD: -1.47, 95% CI: -2.68 to -0.27, p=0.02) as well as improvement in dysmenorrhea with a mean difference -1.92 (95% CI: -3.41 to -0.43, p=0.01) than the placebo group. Antioxidants showed excellent potential to be an alternative treatment in managing endometriosis-related pain, particularly pelvic pain, dyspareunia, and dysmenorrhea. Conclusion: The efficacy of antioxidant agents can be a potential treatment to alleviate pain associated with endometriosis, such as pelvic pain, dysmenorrhea, and dyspareunia.

Quality of life and symptoms of pain in patients with endometriomas compared to those with other endometriosis lesions: a cross-sectional study

BackgroundEndometriomas are genetically distinct from other endometriosis lesions and could be associated with a predisposition to excessive inflammation. However, differences in clinical presentation between types of endometriosis lesions have not been fully elucidated. This study aimed to investigate the quality of life and pain scores of patients with endometriomas compared to those with other types of endometriosis lesions.MethodsA cross-sectional observational study was conducted between January 2020 and August 2023. Patients diagnosed with endometriosis completed the Endometriosis Health Profile 30 pain subscale questionnaire for their quality of life score and rated their endometriosis-associated pain symptoms using an 11-point numerical rating scale. The data were analyzed for comparison through multivariate linear regression models.ResultsA total of 248 patients were included and divided into endometrioma (81, 33%) and nonendometrioma (167, 67%) groups. The mean age of the patients was 37.1 ± 7.5 years. Most participants were Canadian or North American (84%). One-third of the patients reported experiencing up to four concurrent pain symptoms. The most reported pain included deep dyspareunia (90%), chronic pelvic pain (84%) and lower back pain (81%). The mean quality of life score was 45.9 ± 25.9. We observed no difference in quality of life scores between patients with and without endometriomas. Patients with endometriomas had lower mean scores for deep dyspareunia (0.8; 95% CI [0 to 1.5]; p = 0.049) and higher mean scores for superficial dyspareunia (1.4; 95% CI [0.2 to 2.6]; p = 0.028). Comorbid infertility (p = 0.049) was a factor that modified superficial dyspareunia intensity in patients with endometriomas.ConclusionIn patients with endometriosis, evidence was insufficient to conclude that the presence of endometriomas was not associated with a greater or lesser quality of life, but differences in specific symptoms of dyspareunia were identified.

Evaluation of tension-free vaginal tape and transobturator tape surgery performed in one year in terms of mesh erosion

Background/Aim: Mesh erosion is one of the feared complications in surgeries performed using mesh, and its frequency is increasing as more and more of these surgeries are performed. This study aims to evaluate transobturator tape (TOT) and tension-free vaginal tape (TVT) surgeries performed in the surgical treatment of stress urinary incontinence (SUI) in our clinic in terms of clinical results and mesh erosion. Methods: This study is a retrospective cohort study. The files of 50 patients who had SUI and underwent TOT and TVT surgery in our clinic between January 2022 and January 2023 were reviewed. Patients diagnosed with pure SUI and for whom surgery was performed were included in our study. The participants were divided into two groups: those who had TOT surgery and those who had TVT surgery. These groups were evaluated and compared in terms of mesh injury, mesh erosion, pelvic pain, dyspareunia symptoms, and urinary retention. The surgical data of patients, incidence of complications, pre- and postoperative incontinence impact questionnaires (IIQ-7) and the scores of the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) were recorded. Results: The mean follow-up period of the participants was 8.96 (8.47) (range, 6-17 months). TVT surgery was performed on 13 participants and TOT surgery was performed on 37 patients. When the two groups were compared, there was no statistically significant difference in terms of age, body mass index (BMI), parity, menopausal status, duration of incontinence, preoperative IIQ-7 scores, and ICIQ-SF scores (P&lt;0.05). There were no statistically significant differences between surgical durations, length of hospital stay, early surgical complications, postoperative 3rd month IIQ-7, and ICIQ-SF scores (P&lt;0.05). Furthermore, no difference in the rates of mesh erosion and mesh-related complications between the two groups (P&lt;0.05) was observed. Conclusion: TOT and TVT surgeries seem to be quite safe in terms of complications, as well as being satisfactory in terms of patient satisfaction. Although mesh-related complications can be frightening, the rate of regression is low with appropriate management. Our results show that both operations are safe with an acceptable complication rate when performed by surgeons who have experience with anti-incontinence procedures.

Evaluation of effectiveness of pharmacological treatment in pelvic congestion syndrome.

Pelvic congestion syndrome (PCS) is a pain syndrome characterized by positional pelvic pain and is associated with pelvic and vulvar varicosities as well as symptoms of dyspareunia and postcoital pain. Since the etiology of PCS is complex, the treatment should be individualized. Despite both pharmacological and interventional methods being used, there is significant predominance of minimally invasive therapies e.g. embolization. The study considers the answer to the question of whether pharmacological therapy is altogether effective. Using a combination of keywords, a PubMed search was performed for the years 1987-2022. The relevant articles were appointed and included in this narrative review. Despite the multitude of alternatives for pharmacological treatment, the systemic side effects of the medications used, as well as the interactions between drugs, affect patients' compliance and persistence. Furthermore, the quality of the currently existing evidence, considering the efficacy of the given substances, is low. Because of the adverse effects and thus the limited drug administration period, there is currently insufficient research on long-term effectiveness of the PCS pharmacological treatment. Therefore, prospective, comparative studies with larger patient population sizes are necessary to provide the possibility of efficient pharmacological therapy.

Ankyloglossia, a Contributor to Pelvic Pain: A Case Report

Background: Ankyloglossia is a congenital condition of the tongue in which the lingual frenulum is shortened, causing restrictions in the mobility of the tongue. Improper tongue mechanics have an impact on breathing, and impairments can cause a strain on the diaphragm, muscles of the head and neck, as well as the pelvic floor via the connective tissue and fascia. Evidence is largely lacking for the impact ankyloglossia has on pelvic floor function and pain. Case Description: The patient is a 31-year-old woman who reported primary dyspareunia, with significant exacerbation of symptoms postpartum. Six months after the physical therapy initial evaluation she was diagnosed with ankyloglossia, with the frenotomy performed 1 month later. Outcomes: The connective tissue restrictions, muscular restrictions, and myofascial trigger points were addressed via manual therapy. Her planned home exercise program was focused on down-training and breathing. She was initially improving at a slower rate than patients with similar symptoms and history. The first time she attempted intercourse following the frenotomy, she noticed a marked difference in her dyspareunia symptoms and her ability to relax her pelvic floor voluntarily. Discussion: The impact ankyloglossia had on the patient's pelvic floor was missed and her slow progress was attributed solely to other factors. Asking the proper patient history questions and understanding the potential impact that ankyloglossia can have on pelvic floor function can help physical therapists identify an easily missed underlying contributor for pelvic pain.

Effects of preoperative intravaginal estrogen on pelvic floor disorder symptoms in postmenopausal women with pelvic organ prolapse

Menopause and the decline in systemic estrogen are associated with the development of pelvic floor disorders, such as prolapse, urinary incontinence, overactive bladder, and vulvovaginal atrophy symptoms. Past evidence suggests that postmenopausal women with symptomatic prolapse gain benefit from the preoperative application of intravaginal estrogen, but it is unknown whether they would experience improvement in other pelvic floor symptoms when treated with intravaginal estrogen. This study aimed to determine the effects of intravaginal estrogen (compared with placebo) on stress and urgency urinary incontinence, urinary frequency, sexual function and dyspareunia, and vaginal atrophy symptoms and signs in postmenopausal women with symptomatic prolapse. This was a planned ancillary analysis of a randomized, double-blind trial, "Investigation to Minimize Prolapse Recurrence Of the Vagina using Estrogen," which included participants with ≥stage 2 apical and/or anterior prolapse scheduled for transvaginal native tissue apical repair at 3 US sites. The intervention was 1 g conjugated estrogen intravaginal cream (0.625 mg/g) or identical placebo (1:1), inserted nightly for 2 weeks and then twice weekly for ≥5 weeks total before surgery and continued twice weekly for 1 year postoperatively. For this analysis, question responses were compared from participants' baseline and preoperative visits: lower urinary tract symptoms (Urogenital Distress Inventory-6 Questionnaire); sexual health questions, including dyspareunia (Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised); and atrophy-related symptoms (dryness, soreness, dyspareunia, discharge, and itching; each scored 1-4, 4 being quite a bit bothersome). Masked examiners assessed vaginal color, dryness, and petechiae (each scored 1-3, total range 3-9, with 9 being the most estrogenized appearing). Data were analyzed by intent to treat and "per protocol" (ie, those adherent with ≥50% of expected intravaginal cream use, per objective tube before and after weights). Of 199 participants randomized (mean age of 65 years) and contributing baseline data, 191 had preoperative data. The characteristics were similar between groups. Total Urogenital Distress Inventory-6 Questionnaire scores showed minimal change during this median time of 7 weeks between baseline and preoperative visits, but for those with at least moderately bothersome baseline stress urinary incontinence (32 in the estrogen group and 21 in the placebo group), 16 (50%) in the estrogen group and 9 (43%) in the placebo group showed improvement (P=.78). In addition, 43% of participants in the estrogen group and 31% of participants in the placebo group showed improvement in urgency urinary incontinence (P=.41), and 41% of participants in the estrogen group and 26% of participants in the placebo group showed improvement in urinary frequency (P=.18). There was minimal change in the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised scores among sexually active women; dyspareunia rates did not differ between intravaginal estrogen and placebo at the preoperative assessment: 42% and 48%, respectively (P=.49). The maximum score for most bothersome atrophy symptom (among those with baseline symptoms and adherent to study cream) improved slightly more with intravaginal estrogen (adjusted mean difference,-0.33 points; 95% confidence interval,-0.98 to 0.31), but this was not statistically significant (P=.19). However, on examination, among adherent participants, objective signs of atrophy were more improved with intravaginal estrogen treatment (+1.54 vs+0.69; mean difference, 0.85; 95% confidence interval, 0.05-1.65; P=.01). Despite objective changes in the vaginal epithelium consistent with increased estrogenization among drug-adherent participants, the results were inconclusive regarding whether 7 weeks of preoperative intravaginal estrogen cream in postmenopausal women with symptomatic pelvic organ prolapse was associated with improved urinary function, sexual function, dyspareunia symptoms, and other symptoms commonly attributed to atrophy. Additional study is needed.

Effects of Dienogest Therapy on Endometriosis-Related Dysmenorrhea, Dyspareunia, and Endometrioma Size.

Endometriosis is an estrogen-dependent chronic inflammatory disease that is defined by the presence of endometrial-like tissue outside of the uterus. The most common localization is the ovaries, and endometriosis in this location is then called an endometrioma. According to the European Society ofHuman Reproduction and Embryology (ESHRE) (2022) guidelines, the most commonly prescribed treatments for endometriosis include drugs that alter the hormonal milieu. Dienogest is a new generation of progestin used in the treatment of endometriosis. The aim of this study was to assess the effect of Dienogest treatment on endometrioma size and endometriosis-related pain symptoms over a six-month follow-up period. This prospective observational study was conducted at a tertiary clinic in Turkey between March 2020 and March 2021. Here, 64 patients aged 17-49 years with unilateral or bilateral endometriomas without any hormone-dependent cancers and any medical conditions contraindicating the onset of hormonal treatment, such as active venous thromboembolism, previous or current cardiovascular disease, diabetes with cardiovascular complications, current severe liver disease, and not being pregnant, were included. Endometrioma sizes were determined by transvaginal ultrasonography (TVUS). Dysmenorrhea and dyspareunia symptoms were evaluated using the visual analogue scale (VAS). Patients received Dienogest 2 mg/day continuously for six months. At the three- and six-month follow-ups, the patients were re-evaluated. The mean endometrioma size decreased significantly from an initial measurement of 44.0 ± 13 mm to 39.5 ± 15 mm at three months and to 34.4 ± 18 mm at the six-month follow-up. The mean dysmenorrhea VAS scores before treatment, at the three-month follow-up, and at the six-month follow-up were 6.9 ± 2.6, 4.3 ± 2.8, and 3.8 ± 2.7, respectively. Dysmenorrhea VAS scores decreased significantly over the first three months (p<0.01). Similarly, the mean VAS score for dyspareunia decreased at three and six months compared with the pretreatment value (p<0.01). This study shows that dienogest treatment reduced the symptoms of dysmenorrhea and dyspareunia and the size of endometriomas. However, the main significant decrease in dysmenorrhea and dyspareunia symptoms was noted in the first three months, making it a good treatment option, especially in young patients with a fertility wish.

Use of platelet-rich plasma for the treatment of dyspareunia in postmenopausal women

To evaluate the effectiveness of the use of Platelet-rich Plasma (PRP) for the treatment of dyspareunia in postmenopausal women. A psychological, sexological and gynaecological examination of 52 women aged from 45 to 57 (54.4±2.3) with the menopause lasting between 2 and 11 years (7.5±1.2) and with dyspareunia was carried out.Sexological examination included: interview method questionnaire; genitals vascular responses value (duplex Doppler scanning of clitoris vessels in XARIA TOSHIBA machine before and after video-erotic stimulation). Patients were given injections of autologous PRP (6 ml of plasma containing platelet concentration around 1.6 times the baseline where more than 80% are viable) in the region of paraurethral zone, introitus vagina and vagina twice with the interval of 21-22 days. Dyspareunia developed against the background of lubrication disturbance and was accompanied by the reduction of libido (88.5%), formation of secondary anorgasmia (40.4%) and disharmony in relations of partners (32.7%). Doppler scanning of clitoris vessels registered: maximum speed of blood flow (Vsmax) – 1.6–2.3 cm/sec at rest and 3.1–4.1 cm/sec in 30 minutes after video-erotic stimulation; resistance index (IR) – 0.79-0.81 at rest and 0.84-1.0 after the stimulation. Treatment of female sexual dysfunctions was based on the principles of interdisciplinary approach: both individual and couple psychotherapy and a course of PRP therapy (2 procedures). On the 7th day after the PRP therapy we established improvement of lubrication. After the treatment Vsmax of clitoris vessels amounted to 3.7-5.8 cm/sec at rest and 5.3-8.5 cm/sex after the stimulation, IR was 0.51-0.62 and 0.58-0.68 accordingly. As a result of the treatment we established gradual removal of dyspareunia symptoms in 73.1% and reduction of dyspareunia intensiveness in 26.9%. Use of PRP promotes improvement of blood flow in urogenitals, restoration of lubrication and removal of dyspareunia symptoms in postmenopausal women. No conflict of interest.

Menopause and genitourinary health: optimal support and correction of disorders

The vulva, vagina, lower urinary tract, and pelvic floor have the same embryonic origin. Thus, all of the abovementioned organs are equally sensitive to estrogen deficiency and menopausal hormone therapy due to expression of the respective receptors. Genitourinary syndrome of menopause (GSM) is a concept first introduced in 2013 to provide a more complete definition of the consequences of estrogen deficiency in urogenital tissues and reflect the full range of vaginal and urinary symptoms that women experience during menopause. The term broadly reflects the condition, which, unlike the older term “vulvovaginal atrophy”, is not limited to a single symptom of dyspareunia and includes women who are not sexually active. The consequences of GSM significantly alter the quality of life of most menopausal women. Some patients with symptoms of vulvovaginal atrophy completely stop their sexual activity (58 %) and avoid sexual intimacy (55%). Various forms of urinary disorders also alter activities of daily living, sleep, sexual activity, and can lead to social isolation and loss of self-respect. Women with recurrent vulvovaginal infection often have to seek medical care. Estrogen therapy during menopause is pathogenetically justified. Estrogens administered intravaginally are more effective in relieving the symptoms of GSM, both objectively and subjectively, than their systemic use. Up to 40% of women receiving systemic menopausal hormone therapy do not have the expected effect of estrogens on the urogenital tract. If the symptoms of GSM prevail, it is advisable to consider monotherapy with local estrogens or combine it with systemic therapy instead of increasing a dose of the latter. The article presents a clinical case of a personalized approach to solving the issue of vulvovaginal atrophy combined with a mixed urinary incontinence (MUI) in a postmenopausal female patient.

Where does postmenopausal dyspareunia hurt? A cross-sectional report.

A common symptom of genitourinary syndrome of menopause (GSM) is dyspareunia, attributed to vulvovaginal atrophy. Our objective was to systematically describe the pain characteristics and anatomic locations of tenderness in a cohort with moderate/severe dyspareunia likely due to GSM. This cross-sectional study reports the baseline data of postmenopausal women with dyspareunia screened for an intervention trial of topical estrogen. Postmenopausal women not using hormone therapy who had moderate or severe dyspareunia were eligible if estrogen was not contraindicated. Biopsychosocial assessments were performed using the Vulvar Pain Assessment Questionnaire, and participants underwent a systematic vulvovaginal examination that included a visual assessment and cotton swab testing for tenderness rated using the Numerical Rating Scale (0-10). Vaginal pH and mucosal sensitivity were assessed; pelvic floor muscles and pelvic viscera were palpated for tenderness. Fifty-five eligible women were examined between July 2017 and August 2019. Mean age was 59.5 ± 6.8 years, and duration of dyspareunia was 6.2 ± 4.3 years. The mean intercourse pain score was 7.3 ± 1.8, most often described as "burning" and "raw." Ninety-eight percent had physical findings of vulvovaginal atrophy. Median pain scores from swab touch at the vulvar vestibule (just outside the hymen) were 4 to 5/10, and topical lidocaine extinguished pain. Median vaginal mucosal pain was zero. Participants described their pain as "burning" and "dry." Tenderness was most severe and most consistently located at the vulvar vestibule. Correlating the symptom of dyspareunia with genital examination findings may further our understanding of treatment outcomes for GSM.

Suburethral Endometriosis as a Clinical Finding of Extensive Disease - a Case Report and Review of Literature

Study Objective Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Design Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Setting Video laparoscopy, hysteroscopy and cystourethroscopy were performed. Patients or Participants A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Interventions Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Measurements and Main Results Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Conclusion Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions. Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Video laparoscopy, hysteroscopy and cystourethroscopy were performed. A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions.

Pseudotumoral Endometriotic Nodule

To demonstrate a rare case of a pediculated endometriotic nodule that was initially diagnosed as a solid adnexal mass. We present a stepwise narrated demonstration of our laparoscopic technique. We present a case report of a patient aged 44 years, gravida 2 para 2, who was diagnosed with a solid (adnexal) mass during a gynecologic examination. She presented symptoms of dyspareunia. During a bimanual examination, 2 fixed nodules were palpated in both the uterosacral ligaments, and a mobile solid mass of 5 cm could be palpated on the right adnex. A transvaginal ultrasound showed a solid (adnexal) mass of 50 mm in diameter. The tumor marker cancer antigen 125 was normal, and after application of the International Ovarian Tumor Analysis score, the risk of malignancy was up to 39%. A complementary magnetic resonance image showed a heterogeneous solid mass of 47×47×29 mm with a differential diagnosis of a pediculated fibroma in (myxoid) degeneration vs an adnexal solid mass. A laparoscopic unilateral adnexectomy was scheduled, and the patient was informed about the risk of malignancy. The laparoscopy revealed bilateral normal adnexa, the presence of a solid pediculated mass originating from the right uterosacral ligament and 2 endometriotic nodules originating from the left and right uterosacral ligaments. The rectovaginal space was dissected, and a third deep infiltrating endometriotic nodule was revealed. The operation proceeded by the sectioning of the left uterosacral ligament below the endometriotic nodule. The posterior vaginal wall was separated from the endometriotic nodule, and after further dissection of the rectovaginal space, we arrived in a disease-free area. After opening of the right medial division of the pararectal space, the right hypogastric nerve was dissected and preserved. The solid mass was separated from the uterus, the right uterosacral ligament was excised at a distance from the nodule, and the pediculated mass was removed intact en block with the right ligament. The patient was discharged 24 hours after surgery. The postoperative period was uneventful. The definitive histology report confirmed the presence of endometriotic nodules and a solid tumor classified as a pseudotumoral endometriotic mass. This was justified by the presence of conjunctival vascular stroma including multiple endometriotic foci, the presence of cytogenic stroma of variable abundance including glands lined with a columnar epithelium, and, most important, the fact that the epithelium had no cytologic atypias. Laparoscopic excision of the pseudotumoral endometriotic nodule en block with the right and left uterosacral ligaments. Endometriosis is a complex multifactorial pathology in which several factors are involved: genetics, environmental factors, immunologic reactions, hormonal effects, and anatomic anomalies. All these factors may contribute to the creation of an inflammatory response related to immune cells, adhesion molecules, extracellular matrix metalloproteinase, and proinflammatory cytokines enhancing the formation of fibrotic tissue [1,2]. These changes may sometimes have an unusual presentation, as we are showing in this case report of a pseudotumoral endometriotic mass. This rare case should be included in the differential diagnosis of solid tumors before surgery for symptomatic patients and those who have a medical history of endometriosis.

Gartner’s Duct Cyst (Mesonephric Cyst) in Posterior Vaginal Wall

In fetus, the reproductive tract consists of two parts, one male (Wolffian duct) and one female (Mullerian duct), and during embryogenesis, because of hormonal influence, the Mullerian duct system develops to form female genital tract, while the Wolffian duct system regresses and may eventually disappear. Gartner’s cysts arise from the remnant of mesonephric duct (Wolffian duct) and appear only in approximately 1–2% of the population. They are mostly asymptomatic and small but sometimes can be bigger. Here we report a unique case of a large Gartner’s cyst in the posterior vaginal wall with symptoms of dyspareunia and voiding disturbances. After examination, she was diagnosed with vaginal cyst and complete excision was done and confirmed as a mesonephric benign cyst (Gartner’s cyst).

The effect of tubal ligation surgery during cesarean operation on dysmenorrhoea, dyspareunia and menstrual cycle

Background and objectivesThe use of tubal ligation as a contraceptive method has started to increase because it is a safe procedure with high protection. This increase also brings to mind what the procedure-related adverse effects may be. The aim of this study was to investigate the long-term effects whether tubal ligation performed during caesarean had an effect on dysmenorrhea, dyspareunia, menstrual pattern, and hormones. MethodsOur study was retrospectively conducted by archive scanning and phone calls of a total of 220 patients who were divided into two groups as the study group, which underwent tubal ligation during the caesarean section (n = 110), and the control group (n = 110), which had caesarean section but did not undergo tubal ligation. Patients who did not meet the inclusion criteria were not included in the study.The patients were invited to the hospital on the second or third days of their menstrual cycles. Serum TSH, FSH, LH, E2, PRL levels of these patients were studied. Their dysmenorrhoea, dyspareunia symptoms and menstrual cycle patterns were questioned. The results of the groups were compared. ResultsThere was no significant difference between the hormone levels and dysmenorrhoea-dyspareunia evaluations of both groups (p > 0.05). However, it was found that menstrual cycle irregularity was higher in the group that underwent tubal ligation and this difference was statistically significant (p < 0.05). ConclusionIn women who underwent tubal ligation during caesarean section, it was found that there was no difference in menstrual cycle pattern, hormone levels, dysmenorrhea, and dyspareunia, except for menstrual cycle irregularity.

Experience with ospemifene in patients with vulvar and vaginal atrophy and associated sexual dysfunction: case studies

The pathophysiological changes associated with hypoestrogenism of menopause, a condition known as genitourinary syndrome of menopause, are responsible for the hallmark symptoms of vulvovaginal atrophy (VVA), namely dyspareunia secondary to vaginal dryness. Many postmenopausal women with VVA find sexual relations to be challenging or impossible. Ospemifene has estrogen-like effects on the vaginal epithelium, and is indicated to treat moderate-to-severe symptomatic VVA (Europe) or moderate-to-severe symptomatic dyspareunia and vaginal dryness (United States) in postmenopausal women. The case studies presented in this article follow the progress of two women who began treatment with ospemifene for the main presenting symptom of dyspareunia. Both women had concerns about the impact of their symptomatology on new relationships. The patient in case 1 experienced relevant improvement within 3 months of treatment start and, by 1 year, dyspareunia was absent. Vaginal lubricants were no longer required. The patient in case 2 experienced relevant improvement within 4 weeks of starting ospemifene. At 15 months, with the use of a lubricant for vaginal penetration, she could enjoy sexual intercourse without pain. At the time of writing, she had been receiving ospemifene continuously for more than 2 years with effective symptom relief and good tolerability.

Maturation of Vaginal Epithelium and Dyspareunia Symptoms in Equol Producing and Non-Producing Menopausal Women

Introduction: Equol is a metabolite of soy isoflavon called daidzein which is produced by gastrointestinal tract bacteria. This research aims to analyze the maturation of vaginal epithelium and dyspareunia symptoms in producing and non-producing equol menopausal women.Method: This is a cross sectional research. Subject was a community of menopausal women who fulfilled inclusion criteria. Subjects were asked to sign a written informed consent. Subjects underwent vaginal epithelium maturation assessment and were asked whether she experienced dyspareunia. Research was conducted in January 2017.Result: There was a significant difference on the maturation of vaginal epithelium and dyspareunia symptoms between equol producing and non-producing women (p &lt; 0.05). This research found that in equol producing menopausal women, there was a shift-to-the-right vaginal epithelium maturation with more superficial cells compared to parabasal cells produced and less dyspareunia. Meanwhile, in women who did not produce equol, there was a shift-to-the-left vaginal epithelium maturation with more parabasal cells compared to superficial cells produced and more dyspareunia.Conclusion: In equol producing menopausal women, vaginal epithelium will undergo a shift-to-the-right maturation, with more superficial cells produced compared to women who did not produce equol.Maturasi Epitel Vagina dan Gejala Dispareunia pada Wanita Menopause yang Menghasilkan Equol dan Wanita yang Tidak Menghasilkan EquolAbstrakPendahuluan: Equol adalah metabolit isoflavon kedelai yang disebut daidzein yang diproduksi oleh bakteri saluran pencernaan. Penelitian ini bertujuan untuk menganalisis maturasi epitel vagina dan gejala dispareunia pada wanita menopause yang memproduksi dan tidak memproduksi equol.Metode: Penelitian ini merupakan penelitian cross sectional. Subjek penelitian adalah sekelompok wanita menopause yang memenuhi kriteria inklusi. Subjek diminta untuk menandatangani persetujuan tertulis dan menjalani penilaian maturasi epitel vagina dan ditanya apakah mengalami dispareunia. Penelitian dilakukan pada Januari 2017.Hasil: Terdapat perbedaan yang signifikan pada maturasi epitel vagina dan gejala dispareunia antara wanita yang memproduksi equol dan yang tidak memproduksi (p &lt;0,05). Pada wanita menopause yang memproduksi equol, terjadi pematangan epitel vagina shift-to-the-right disertai produksi sel superfisial yang lebih banyak dibandingkan sel parabasal dan lebih sedikit gejala dispareunia. Sementara itu, pada wanita yang tidak menghasilkan equol, terjadi pergeseran shift-to-the-left maturasi epitel vagina dengan produksi sel parabasal lebih banyak dibandingkan sel superfisial dan lebih sering gejala dispareunia.Kesimpulan: Wanita menopause yang memproduksi equol mengalami maturasi epitel vagina shift-to-the-right disertai produksi sel superfisial yang lebih banyak dibandingkan dengan wanita menopause yang tidak memproduksi equol.Kata kunci: Dyspareunia; equol; maturasi epitel vagina

Maturation of Vaginal Epithelium and Dyspareunia Symptoms in Equol Producing and Non-Producing Menopausal Women

Introduction : Equol is a metabolite of soy isoflavon called daidzein which is produced by gastrointestinal tract bacteria. This research aims to analyze the maturation of vaginal epithelium and dyspareunia symptoms in producing and non-producing equol menopausal women. Method : This is a cross sectional research. Subject was a community of menopausal women who fulfilled inclusion criteria. Subjects were asked to sign a written informed consent. Subjects underwent vaginal epithelium maturation assessment and were asked whether she experienced dyspareunia. Research was conducted in January 2017. Result : There was a significant difference on the maturation of vaginal epithelium and dyspareunia symptoms between equol producing and non-producing women (p &lt; 0.05). This research found that in equol producing menopausal women, there was a shift-to-the-right vaginal epithelium maturation with more superficial cells compared to parabasal cells produced and less dyspareunia. Meanwhile, in women who did not produce equol, there was a shift-to-the-left vaginal epithelium maturation with more parabasal cells compared to superficial cells produced and more dyspareunia. Conclusion : In equol producing menopausal women, vaginal epithelium will undergo a shift-to-the-right maturation, with more superficial cells produced compared to women who did not produce equol. Maturasi Epitel Vagina dan Gejala Dispareunia pada Wanita Menopause yang Menghasilkan Equol dan Wanita yang Tidak Menghasilkan Equol Abstrak Pendahuluan : Equol adalah metabolit isoflavon kedelai yang disebut daidzein yang diproduksi oleh bakteri saluran pencernaan. Penelitian ini bertujuan untuk menganalisis maturasi epitel vagina dan gejala dispareunia pada wanita menopause yang memproduksi dan tidak memproduksi equol. Metode : Penelitian ini merupakan penelitian cross sectional. Subjek penelitian adalah sekelompok wanita menopause yang memenuhi kriteria inklusi. Subjek diminta untuk menandatangani persetujuan tertulis dan menjalani penilaian maturasi epitel vagina dan ditanya apakah mengalami dispareunia. Penelitian dilakukan pada Januari 2017. Hasil : Terdapat perbedaan yang signifikan pada maturasi epitel vagina dan gejala dispareunia antara wanita yang memproduksi equol dan yang tidak memproduksi (p &lt;0,05). Pada wanita menopause yang memproduksi equol, terjadi pematangan epitel vagina shift-to-the-right disertai produksi sel superfisial yang lebih banyak dibandingkan sel parabasal dan lebih sedikit gejala dispareunia. Sementara itu, pada wanita yang tidak menghasilkan equol, terjadi pergeseran shift-to-the-left maturasi epitel vagina dengan produksi sel parabasal lebih banyak dibandingkan sel superfisial dan lebih sering gejala dispareunia. Kesimpulan: Wanita menopause yang memproduksi equol mengalami maturasi epitel vagina shift-to-the-right disertai produksi sel superfisial yang lebih banyak dibandingkan dengan wanita menopause yang tidak memproduksi equol. Kata kunci : Dyspareunia; equol; maturasi epitel vagina