Vulvar Biopsy Research Articles

Typing of Vulvar Squamous Cell Carcinoma: Why it is Important?

The classification of vulvar squamous cell carcinoma (VSCC), as in endometrial cancer, has shifted from the histology-based descriptors toward molecular-based identifiers. Recently, it has been reported that there are 3 genetically distinct and clinically significant subtypes of VSCC: HPV-associated VSCC, HPV-independent/p53 wild-type VSCC, and HPV-independent/p53-mutated VSCC. Each group has different prognostic implications as well as response to treatment, thus reinforcing the need for this 3-tier molecular classification. This molecular subtyping can easily be done on vulvar biopsies using p16 and p53 immunohistochemistry stains to further improve risk prediction and individualized treatment decisions, leading to better patient outcomes.

Primary mucinous adenocarcinoma intestinal type of the vulva arising at site of prior vulvar Crohn’s disease: A case report and review of the literature

Introduction: Vulvar mucinous adenocarcinoma is a rare subtype that likely arises from atopic gastrointestinal tissue. The evaluation and treatment of this condition often requires a multidisciplinary approach. Case Report: Our patient is a 55-year-old female with a history of Crohn’s disease who initially presented with a painless vulvar mass associated with occasional bleeding. Notably, the mass presented at the site of a prior rectovaginal fistula. A vulvar biopsy was performed with pathology consistent with intestinal type mucinous adenocarcinoma. Further workup was notable for imaging showing retroperitoneal and pelvic metastatic lymphadenopathy, hypermetabolic liver and bony metastases, and pulmonary nodules concerning for metastases. Following discussion at tumor board, the patient was recommended treatment with 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), and bevacizumab. Unfortunately, prior to starting chemotherapy, the patient presented to the emergency department with dizziness and weakness and was found to have brain metastases. She ultimately elected to be discharged home on hospice care. Conclusion: Vulvar mucinous adenocarcinoma is a rare subtype tumor with limited literature on treatment options. For these rare cases, clinicians can consider treatment modalities for colon carcinomas rather than vulvar carcinomas.

Nonsclerotic Lichen Sclerosus of Vulva: A Clinicopathologic Analysis.

The International Society of the Study of Vulvovaginal Diseases (ISSVD) recently defined nonsclerotic lichen sclerosus (NSLS) as a scenario wherein the clinical findings are consistent with lichen sclerosus (LS), but no microscopic evidence of dermal sclerosis is found and recognized 4 histologic subcategories. Herein, we present an institutional experience with NSLS, with an emphasis on frequency, application of the ISSVD categories in routine practice, and clinicopathologic correlation. The authors reviewed clinical and pathologic findings for consecutive vulvar biopsies in which LS was a clinical and/or pathologic consideration. Cases were classified as classical/sclerotic LS (CLS), NSLS (per ISSVD criteria), and "unclassified," the latter of which were cases not classifiable as NSLS or CLS, despite a clinical impression or LS or LS being a significant clinical consideration (ie, "clinical LS"). In clinical LS cases, CLS and NSLS were diagnosed histologically in 61% (182/298) and 15% (44/298), respectively, whereas the remainder were histologically unclassified. The latter group was microscopically heterogeneous, devoid of a consistent pathologic profile, and generally showed absence, focality, minimality, ambiguity, or infrequency of features that would have allowed their categorization into one of the NSLS categories. Among the 4 categories for the categorizable NSLS cases, the "lichenoid dermatitis" pattern (61.4%) was the commonest, followed by dermal fibrosis with acanthosis (22.7%), dermal fibrosis without acanthosis (9.1%), and hypertrophic lichenoid dermatitis (6.8%). The clinical response rates to topical therapies for the NSLS and unclassified groups were 71% and 62%, respectively (P=0.4). Our findings highlight the significance of clinicopathologic correlation in the diagnosis of NSLS. In the setting of clinical LS, some histologic evidence to support that impression is found in most cases when the ISSVD system for diagnosis and classification of biopsies is applied. However, a subset of clinical LS cases are not pathologically classifiable as either CLS or any of the NSLS categories; these display nonspecific histologic features and require future study.

Case Report: Radical Vulvectomy V-Y Flap Surgical Procedure in a Woman with Vulva Cancer

Introduction: Vulva cancer is one of the relatively rare malignancies, accounting for only 4% of all malignancies in gynecologic organs. Vulva cancer is often asymptomatic. Surgery is the basic management in patients with earliest-stage vulvar cancer and frequently requires a combined radical vulvectomy followed by inguinal LN dissection through a separate incision. Therefore, the author hopes this case can add insight into the knowledge related to early detection and comprehensive management of vulva cancer. Case Presentation: A woman, 67 years old, referred from Gambiran General Hospital Kediri with a vaginal biopsy result of vulva cancer, came to the Saiful Anwar General Hospital oncology clinic. The patient complained of pain in the pubic area accompanied by tissue growth around the pubic area since August 2023. History of weight loss (+) 10 kg in the past year. History of menopause since 18 years ago. The examination results obtained vital signs: BP 132/79 mmHg, pulse 128x/min, RR 20x/min, temperature 36.5C, height 155 cm, weight 40kg, and BMI 16.64 kg / m2 (underweight). Physical examination of external genitalia revealed a 12x8 cm mass on the right vulva, odour (+). The results of the vulvar biopsy examination on 25/08/2023 were found to be squamous cell carcinoma, well differentiated. The patient is planned for elective-wide excision. The management performed was radical vulvectomy with V-Y flap reconstruction surgery. Conclusion: In this case, it can be concluded vulva cancer is a relatively rare malignancy. The subtype often found is SCC (90-95%). This patient planned for radical vulvectomy using the V-Y flap reconstruction technique with SAB.

(096) UNDERSTANDING THE RELATIONSHIP BETWEEN CHRONIC PAIN AND DEPRESSION IN LOCALIZED PROVOKED VULVODYNIA

Abstract Introduction Localized provoked vulvodynia (LPV) is a disease characterized by chronic pain in the vulva in response to touching the vulvar vestibular epithelium. As with other chronic pain disorders, vulvodynia is often found accompanied with depression, and depressive symptoms aggravate pain severity and persistence. While there is clear evidence of a connection between chronic vulvar pain and depression, the mechanism of this bidirectional relationship is largely unknown. Accumulating evidence suggests that inflammation plays a central role in depression. Since the pathophysiology of LPV also involves inflammation, we aim to better understand these relationships by pharmacologically inhibiting the enzyme that plays a key role in both inflammation and depression: soluble epoxide hydrolase (sEH). Objective To elucidate the role of sEH in localized provoked vulvodynia, which might be involved in the chronic pain and depression comorbidity prevalent in vulvodynia patients, and discuss the clinical significance of using sEH inhibitors, such as 1-trifluoromethoxyphenyl-3-(1-propionylpiperidin-4-yl) urea (TPPU), for patients suffering from this condition. Methods Vulvar punch biopsies obtained from painful sites within the vulvar vestibule and non-painful sites within the external vulva of 6 LPV patients and 6 age/race-matched healthy controls were used to generate a library of primary fibroblast strains. Cells were treated with the inflammatory instigator interleukin-1β (IL-1β) and TPPU. Quantitative PCR, Western blotting, and enzyme-linked immunosorbent assays were used to assess the effects of sEH inhibition. Statistical analysis was performed using GraphPad Prism 10.0.2. Comparisons among groups were performed using the one-way analysis of variance (ANOVA) or two-way ANOVA, followed by post-hoc Tukey test. Results Vulvodynia patients produce increased levels of pro-inflammatory cytokines, namely interleukin-6 (IL-6) and prostaglandin E2 (PGE2), when compared with controls. Interestingly, mRNA (P = 0.0091) and protein (P = 0.0198) levels of sEH were significantly lower in the painful vestibule of these patients. When sEH was inhibited with TPPU, we observed a significant decrease in IL-6 levels (P = <0.0001), but not PGE2 (P = 0.6452). These preliminary findings are of fundamental importance as cytokines can directly contribute to the development of depressive symptoms. Conclusions Patients with vulvodynia are more likely to develop depressive symptoms than patients without vulvar pain. Likewise, patients with depression are more likely to develop vulvodynia than patients without depression. Our results suggest that sEH may play a role in this bidirectional mechanism, which could serve as a novel therapeutic target for chronic pain and depression comorbidity. Disclosure No.

Feasibility study of focused ultrasound in the treatment of vulvar low-grade squamous intraepithelial lesions with persistent symptoms

Objective This study aimed to investigate the feasibility, efficacy, and safety of focused ultrasound (FUS) for the treatment of vulvar low-grade squamous intraepithelial lesions (VLSIL) with persistent symptoms. Methods This retrospective analysis included 24 VLSIL patients who underwent FUS treatment. At each follow-up visit, the clinical response was assessed including changes in symptoms and signs. In addition, the histological response was assessed based on the vulvar biopsy results of the 3rd follow-up. Clinical and histological response were assessed to elucidate the efficacy. Results A total of 22 patients completed follow-up and post-treatment pathological biopsies. After treatment, the clinical scores of itching decreased from 2.55 ± 0.51 to 0.77 ± 0.81 (p < 0.05). Furthermore, the clinical response rate and histological response rate were 86.4% and 81.8%, respectively. Only two cured patients indicated recurrence in the 3rd and 4th year during the follow-up period and achieved cure after re-treatment. In terms of adverse effects, only one patient developed ulcers after treatment, which healed after symptomatic anti-inflammatory treatment without scarring, and no other treatment complications were found in any patients. None of the patients developed a malignant transformation during the follow-up period. Conclusion This study revealed that FUS is feasible, effective, and safe for treating VLSIL patients with persistent symptoms, providing a new solution for the noninvasive treatment of symptomatic VLSIL.

Vulvar skin disease in the pediatric population.

Vulvar skin disease is an underrecognized pediatric condition encompassing a wide range of conditions, from isolated vulvar disease to vulvar manifestations of systemic illnesses. This review highlights the most current research discussing clinical features, risk factors, and treatments. Recent studies confirm that labial adhesions resolve more quickly with estrogen treatment. Topical corticosteroids remain first-line for treatment of vulvar lichen sclerosus, and some procedural interventions are showing promising results. Latest evidence shows efficacy of biologic agents in hidradenitis suppurativa and vulvar Crohn's. Vaginal voiding remains an underrecognized cause of irritant vulvovaginitis. Lately vulvar aphthae have been associated with coronavirus disease 2019. Distinguishing between infantile perianal pyramidal protrusion, molluscum, and condyloma can be aided by differences in morphologic features. Vulvar dermatoses have a high impact on children's health and wellbeing. Clinician familiarity with recognition and latest advancements in vulvar dermatoses can aid in prompt diagnosis, management, and appropriate referrals. Vulvar biopsy and vaginal cultures should be used prudently. Treatments include topicals, behavioral modification, systemic medications, and procedures.

Molecular Classification of Vulvar Squamous Cell Carcinoma and Precursor Lesions Using Immunohistochemistry

Abstract Introduction: Vulvar malignancies are very rare. Two pathogenic pathways have been described in the development of vulvar squamous cell carcinoma.One is related to HPV infection and the other is related to TP 53 mutation. HPV infection related squamous cell carcinomas have a good prognosis and squamous cell carcinomas related to TP 53 mutation have the worst prognosis. Recently a third pathway which is neither HPV dependent nor p53 mutant has been identified. This pathway is found to have intermediate prognosis with better clinical outcome. Aims: The aim of this study was to classify vulvar squamous cell carcinoma and its precursor lesions molecularly using two immunohistochemical stains p16 and p53 in a cohort of South Indian population. Subjects and Methods: A retrospective observational study was conducted between January 2011 and December 2020 in the department of histopathology at a tertiary care hospital in Hyderabad, India. A total of 22 cases including all the vulval biopsies with suspected squamous cell carcinoma or precursor lesions and excision specimens operated for squamous cell carcinoma were included in this study. Paraffin blocks of representative cases were stained with hematoxylin and eosin stain, p16 and p53 immunohistochemistry (IHC) stains. Results: Out of 22 cases, two cases (9.0%) were precursor lesions of the vulva and 20 cases (90.9%) were invasive squamous cell carcinoma. Eleven (50%) of these cases were p53 mutant (p53+/p16−), 10 (45.4%) of these cases were HPV positive (p16+/p53−), and one of these cases (4.5%) was neither HPV positive nor p53 mutant (p16−/p53−). Conclusions: Classification of vulvar squamous cell lesions molecularly using simple immunohistochemical stains in routine diagnostic workup will aid in risk stratification of patients and help in their management and prognostication.

Exploring the potential prompting role of cervical human papilloma virus detection in vulvar lesions: a cross-sectional study in China.

The etiology and clinical presentation of vulvar carcinomas, especially vulvar lesions, are not fully understood. Because the vulva and cervix are anatomically connected, human papillomavirus (HPV) is the main cause of cervical lesions. Thus, this study explored the potential characteristics and effects of specific HPV infection types across vulvar lesions and concurrent cervical lesions. This retrospective, cross-sectional study analyzed patients with cervical HPV or cytological results and concurrent vulvar biopsy who were seen in our hospital colposcopy clinic in Shanxi Province, China, between 2013 and 2023. Data on age, menopause status, vulvar manifestations, and cytology and HPV infection testing results were collected. Attributable fractions and multinominal logistic models were used to evaluate HPV genotyping and clinical characteristics across vulvar lesions. Among the 1,027 participants, 83 (8.1%) had vulvar intraepithelial neoplasia (VIN) of high grade or worse (VIN2+), and 127 (12.4%) had non-neoplastic epithelial disorders of the vulva (NNEDV). A total of 175 patients had either VIN2+ or cervical intraepithelial neoplasia (CIN) lesions of grade 2 or worse (CIN2+). The most common HPV genotypes for VIN2+ or concurrent VIN2+/CIN2+ were HPV16, HPV52, and HPV58, although attributable fractions differed among lesions. Patients with normal cytological or histopathological result were more likely to have NNEDV detected, while abnormal cervical diagnosis was associated with higher detection of VIN2+. Multinominal logistic modeling showed that age and HPV16 infection were risk factors for VIN2+ or concurrent VIN2+/CIN2+; however, only vulvar presentation with depigmentation was a risk factor for NNEDV. Among patients with low-grade CIN1/VIN1, compared with those who were HPV16 negative, those who were HPV16 positive were at 6.63-fold higher risk of VIN2+/CIN2+ [95% confidence interval (CI): 3.32, 13.21]. Vulvar depigmentation was also associated with increased risk of NNEDV (odds ratio: 9.98; 95% CI: 3.02, 33.04). Chinese women may be at specific, high risk for HPV infection types associated with VIN or CIN. The use of cervical cell HPV detection along with vulvar presentation during cervical cancer screening may also contribute to vulvar lesion detection.

Investigation of vulvar biopsy results in patients with vulvar clinical complaints

Investigation of vulvar biopsy results in patients with vulvar clinical complaints

Wide Local Excision versus Simple Vulvectomy in Vulval Intraepithelial Neoplasia 3: Case Report and Literature Review

Vulvar intraepithelial neoplasia is a premalignant lesion of the vulva. Women with vulvar cervical intraepithelial neoplasia 3 are at high risk of recurrence and vulvar carcinoma. They warrant a surgical management for the same reason. It may be either ablative or excisional, sometimes can be a combination of both. The decision for wide local excision or simple vulvectomy depends on clinical factors. Case: We present a case of a 67-year-old lady who presented with vulvar itching and a large black vulvar lesion involving the fourchette area, with HPV 16 positive. Initially, there was a doubt of melanoma, but vulval biopsy was suggestive of high-grade squamous intraepithelial lesion (HSIL) (vulval intraepithelial neoplasia 3 [VIN 3]). As it was a single large lesion, the initial plan was wide local excision but as the lesion was large and occupying almost half of the vulva, the decision of simple vulvectomy was taken. A wide local excision would have resulted in vulvar asymmetry and since there was a big lesion, chances of satellite lesions over the vulva were there; decision was made for simple vulvectomy. In this case report, we will review the literature on the surgical management of VIN 3. Conclusion: Treatment is recommended for all vulvar HSIL because of the potential for invasion. Simple vulvectomy is an easy procedure, with less hospital stay, less blood loss, and least recurrence rates. It is a suitable treatment option for multifocal and large lesions of the vulva.

Vulvar biopsy: Punch biopsy or cervical forceps biopsy?

ObjectivesThe primary objective of our study is to investigate the rate of non-contributory biopsies between punch biopsy(PB) and cervical forceps biopsy(CFB) for a vulvar lesion seen in consultation.The secondary objective of our study is to evaluate the rate of underestimation of a more severe lesion for patients who have undergone vulvar excision. Material and methodThis is a retrospective, descriptive, and comparative study conducted at three centers. The study population consisted of patients who underwent vulvar biopsy between 2017 and 2022 in a gynecological surgery consultation at two French hospitals, as well as a city office. The biopsy techniques used were punch or cervical forceps biopsy. Quantitative variables were analyzed using the Mann-Whitney test, while Pearson's or Fisher's Xi2 tests were used for qualitative variables. The significance level was set at 5%. ResultsWe conducted a retrospective study of 179 vulvar biopsies, of which 100 were punch biopsies and 79 were cervical forceps biopsies, from a total of 107 patients.There was no significant difference in the rate of non-contributory biopsies between the PB and CB groups (p = 1).When analyzing the secondary endpoint of our study, which included 68 patients who underwent vulvectomy after vulvar biopsy, we found that 66 patients (97%) had a good correlation between the pathology of the vulvar biopsy and that of the vulvectomy specimen. ConclusionVulvar biopsy techniques using punch or cervical forceps appear to have similar diagnostic performance and are associated with comparable and low rates of underestimation of invasive lesions.

Idiopathic Lichenoid and Granulomatous Vulvitis: A Distinct Clinicopathological Entity.

The combination of lichenoid and granulomatous inflammation is uncommon in vulval biopsies. We present a series of 5 patients with lichenoid and granulomatous vulvitis, presenting with clinical changes resembling lichen sclerosus. Despite detailed clinicopathological investigation and follow-up, there was no apparent association with an underlying recognized cause. All 5 cases occurred in postmenopausal women and displayed a distinctive histological pattern of superficial band-like inflammation with granulomas "anchored" to the dermoepidermal junction. There was no evidence of deeper granulomatous inflammation. Despite repeated biopsies over 2 years in 2 patients, neither developed typical histological features of lichen sclerosus. We postulate that idiopathic lichenoid and granulomatous vulvitis may represent a distinct clinicopathologically defined vulvar dermatosis.

Fat Grafting in Vulvar Lichen Sclerosus: Long Term Follow-Up.

The rationale for the use of autologous fat grafting in the treatment of vulvar lichen sclerosus (VLS) consists in reduction of inflammation, regeneration of tissues, volume increase, and pain fiber control. The main outcome of this study was the evaluation of patients' satisfaction after treatment. Secondary outcomes included modifications in symptoms, psychosexual wellbeing, vulvar hydration, and histology after surgery. Eligible for this study were women aged 18-85 years with a histological diagnosis of VLS who underwent at least one autologous vulvar fat grafting at the authors' center, between 2010 and 2019. In 2021, all women underwent a clinical reevaluation, comprehensive of vulvoscopy, vulvar biopsy, and handing out of validated questionnaires. Overall, 88.7% of patients declared themselves very satisfied/satisfied with the procedure. All symptoms were improved postsurgery; in particular, the difference was statistically significant for pruritus, burning, and dyspareunia ( p < .05). Sexual function was also improved at time of reevaluation, as were depressive and anxiety symptoms ( p < .05). No cases of vulvar intraepithelial neoplasia or cancer occurred during follow-up and vulvar architecture remained stable, although patients reported a significantly reduced need for topical steroids ( p < .0001). Lastly, in postoperative biopsies, inflammatory infiltrate was stable or reduced, and the distribution of elastic fibers was comparable or restored in most patients. Patient satisfaction with fat grafting is detectable up to 11 years after surgery, and as such, it may represent a valid therapeutic option in selected cases of VLS.

Vulvar Lichen Sclerosus Clinical Severity Scales and Histopathologic Correlation: A Case Series.

Several vulvar lichen sclerosus (VLS) clinical severity scales have recently been proposed. In this prospective case series, we characterized histopathology in the context of clinical severity in 6 treatment-naïve postmenopausal patients with VLS. The Vulvar Quality of Life Index (VQLI) and an adaptation of the 2018 International Society for the Study of Vulvovaginal Disease Delphi consensus VLS severity score were administered. Vulvar skin punch biopsies were obtained to measure inflammatory density, constituent inflammatory cells, thickness of the stratum corneum and other epidermal layers, dermal edema, and dermal sclerosis. Clinicopathologic correlations were assessed. Two cases demonstrated sparse inflammatory densities, 1 case demonstrated patchy and nodular inflammatory density, 1 case demonstrated dense lichenoid inflammatory density, and 2 cases demonstrated dense lichenoid and epitheliotropic inflammatory densities. Those patients who reported severe pruritus demonstrated the greatest lymphocytic inflammatory densities on histopathological examination. Both cases of ulceration or erosion were associated with severe VQLI scores. Severe VQLI scores were also associated with trends for higher average thickness of the epidermal layers and of dermal sclerosis. Altogether, histopathologic grading of biopsy sites may reflect clinical severity in patients with VLS.

A Prospective Study to Assess for Histologic Changes on Vulvar Biopsies in Postmenopausal Women With Lichen Sclerosus Treated With Fractionated CO2 Laser Therapy [ID: 1339895

INTRODUCTION: Lichen sclerosus (LS) is a chronic skin condition affecting men and women of all ages. Fractionated carbon dioxide (FxCO2) laser therapy has been proposed as a novel treatment modality. Our objective was to investigate histologic changes after FxCO2 laser therapy for vulvar LS and assess symptomatic improvement using the Skindex-16 questionnaire. METHODS: This prospective single-arm study was conducted from April 2021 to August 2022 at one academic medical center. Ten English-speaking postmenopausal women with biopsy-proven LS undergoing FxCO2 laser treatment were enrolled. Exclusion criteria included prior transvaginal mesh for prolapse, recent topical corticosteroid use, prior pelvic radiation, malignancy, active genital infection, or pregnancy. Institutional review board approval and written consent from participants were obtained. The vulvovaginal SmartXide2-V2-LR laser system FxCO2 laser (DEKA, Calenzano, Italy) was used to treat visually affected areas of vulvar and perianal LS with a single pass over three treatments spaced 4–6 weeks apart. Participants completed the Skindex-16 questionnaire and underwent vulvar biopsy at baseline and 4 weeks after the third FxCO2 laser therapy. Histologic slides were blinded and then scored by a dermatopathologist (MC) on a 5-point scale to assess sclerosus, inflammation, and epidermal atrophy. RESULTS: Participants had a mean age of 61 and were mostly White, privately insured with college/graduate-level education. Posttreatment vulvar biopsies showed significant improvement in sclerosus and epidermal atrophy (P&lt;.05) with no statistically significant change in inflammation or Skindex-16 scores after FxCO2 laser treatment. A statistically significant correlation was found between sclerosus and Skindex-16 symptoms score (mean change of 21.4 units in Skindex-16 symptoms score for 1 unit change in histologic sclerosus score, P=.03). CONCLUSION: In postmenopausal women with vulvar LS undergoing FxCO2 laser therapy, symptomatic improvements are correlated with histologic changes in sclerosus on vulvar biopsy. FxCO2 laser therapy is a promising option for treatment of LS, and further studies are needed to assess safety and efficacy.

Neuroendocrine carcinoma of the vulva, a rare entity. Report of the first case in Venezuela.

Vulvar cancer represents 1% of cancers in women; vulvar neuroendocrine carcinoma is extremely rare, with less than 20 published cases. Its behavior is very aggressive, producing early local recurrences, lymph node and distant metastases. The case of a 60-year-old patient who consulted for a vulvar lesion of 6 months of evolution, with extension to the lower third of the urethra and vagina and left inguinal nodal plastron is described. The vulvar biopsy reported malignant round cell neoplasm and the immunohistochemistry result was compatible with neuroendocrine carcinoma. She received concurrent chemotherapy and radiotherapy, evidencing a complete response in the vulva and a partial response in the inguinal region.Later, bilateral inguinofemoral lymphadenectomy was performed. Neuroendocrine carcinoma of the vulva should be considered when managing malignant vulvar pathology, timely diagnosis requires histology and immunohistochemistry to establish an adequate prognosis and treatment.

Metronidazole for the treatment of cutaneous vulval Crohn disease: A systematic review.

Cutaneous vulval Crohn disease (VCD) is an under-recognised extra-intestinal manifestation of Crohn disease (CD) which is challenging to identify and treat. It causes significant oedema, painful deep fissures, and has potential to cause permanent disfiguring changes to vulval anatomy. There is no agreement on the best management for VCD. This systematic review evaluates the use of metronidazole for the treatment of VCD in women and children. We conducted a systematic review (PROSPERO CRD42021285033) of the use of metronidazole in clinically or histologically diagnosed non-contiguous VCD in patients of all ages and ethnicities. We recorded clinical improvement, reduction in flares, relapse and adverse events using a standardised form. 49 records (40 case reports and 9 case series) met inclusion criteria, comprising a total of 57 patients with an age range of 5-61years. The most reported presenting features in VCD were: oedema, erythema, ulcers/fissures and induration/thickening. Gastrointestinal CD was present in 33/57 (58%). Vulval biopsies were undertaken in 47/57 (83%). Daily doses ranged from 250 to 1500mg with treatment duration 8days to 18months. Improvement of any magnitude was observed in 40/57 (70%) cases. Relapse was described in 11/57 (19%) cases. No response/worsening was reported in 17/57 (30%) cases. Adverse events occurred in two patients. Metronidazole appears to be useful in managing VCD, either as a primary treatment or adjunctive therapy. However, the evidence is insufficient for firm conclusions to be drawn. Further studies including randomised controlled trials are recommended.

Diagnosis, causes, and treatment of dyspareunia in postmenopausal women.

Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women. This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia. Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO 2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists. Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.

Morphological features of various variants of the course of scleroatrophic lichen of the vulva

Relevance. Most of the scientific papers presented in the literature indicate morphological features of the stages of development of sclerotic lichen of the vulva, or in comparison with other vulvar skin lesions. At the same time, data on the features of morphological examination of vulvar biopsies, depending on the clinical variants of the course of sclerotic lichen of the vulva, is currently insufficient. The aim of the study - to determine the presence or absence of distinctive morphological features of the sclerotic lichen of the vulva, depending on the clinical variants of its course. Materials and Methods. The study included 292 patients with sclerotic lichen of the vulva (20-70 years old). Based on the scale of assessment of objective and subjective clinical signs of sclerotic lichen of the vulva developed by us, 3 clinical groups: 101 patients with an atrophic variant of the course, 154 with a sclerosing variant and 37 patients with a scleroatrophic variant of the course of sclerotic lichen of the vulva. In addition to clinical laboratory, instrumental and immunological studies, all patients underwent incisional biopsy of the vulva followed by morphological examination of biopsies. Results and Discussion. The features of the results of morphological examination of various clinical variants of the course of sclerotic lichen of the vulva are described and presented in the form of images. The characteristic morphological signs for each clinical group, as well as common signs characteristic of all variants of the course of this pathology, were revealed. Morphological examination of vulvar tissues is informative only to confirm the diagnosis of «Sclerotic lichen of the vulva», to determine the stage of the disease, as well as to exclude the malignant process, while for a clear differentiation of variants of the clinical course of sclerotic lichen of the vulva, conventional morphological examination is not enough, which requires further studies using immunohistochemical and molecular genetic methods. Conclusion. The revealed differences in morphological parameters of various variants of the course of sclerotic lichen of the vulva are insufficiently specific, which excludes the possibility of accurate morphological verification of the variants of the course of sclerotic lichen of the vulva and confirms the expediency of using clinical classification of variants of the course of sclerotic lichen of the vulva based on objective and subjective clinical signs.