Vulvar Symptoms Research Articles

Loss, shame and secrecy in women's experiences of a vulval skin condition: A qualitative study.

Vulval lichen sclerosus (LS) is a chronic dermatological condition affecting the anogenital area, causing intense itching, pain and bleeding. It can change the terrain of the vulva, causing loss of vulval anatomy and altered texture and appearance of the skin. There has been little research into how women experience the materialities of a dermatological vulval disease. We aimed to understand experiences of living with LS, using a feminist lens to examine the influence of societal attitudes towards women's bodies and the vulva. We conducted qualitative interviews with 20 women with vulval LS, taking a critical feminist grounded theory approach. While we found that women's experiences of vulval LS symptoms was normalised as a part of womanhood, there was a silencing of speech about the vulva generally, and vulval symptoms more specifically. This caused profound shame and loneliness, and was a barrier to disclosing and seeking help for vulval symptoms, leading to delayed diagnosis and disease progression. Loss of vulval architecture resulted in a loss of (feminine) self and the sense of a body which was whole.

(071) IMPROVING TRAINEE COMFORT IN ASSESSMENT AND MANAGEMENT OF FEMALE SEXUAL HEALTH AND MENOPAUSE THROUGH AN INTERACTIVE WORKSHOP

Abstract Introduction Concerns related to female sexual health and menopause are common in clinical practice, but these topics are often inadequately covered during training. Many medical schools and residency programs lack a formal curriculum, and trainees in internal medicine, family medicine, and obstetrics and gynecology often graduate feeling uncertain in their management of these conditions. Objective Improve resident comfort with assessment and management of female sexual health and menopause through an interactive workshop. Methods We created a 90-minute, interactive workshop focused on female sexual health and menopause. Residents in internal medicine at a large academic medical center were invited to participate. A multidisciplinary group including physicians, advanced practice providers, registered nurses and a certified sex therapist were recruited to lead the workshop. Results Participants rotate through three 30-minute sessions targeted to learning objectives. One session focuses on conducting a symptom-based pelvic exam. A 3-dimensional model is used to review the anatomy of the female pelvic floor and demonstrate physical exam techniques to evaluate vaginal and vulvar symptoms, pelvic pain, and dyspareunia. Diagnostic skills include vulvar inspection to assess for skin and mucosal changes, cotton swab test of the vestibule, and assessment of pelvic floor musculature. A second session focuses on the genitourinary syndrome of menopause (GSM). The pathophysiology, presentation and treatment of GSM is introduced. Next, registered nurses with expertise in female sexual health and menopause lead an interactive demonstration of vaginal moisturizers and lubricants. Advice for counseling patients on the proper use and application of vaginal estrogens is also reviewed. The final session focuses on sexual health counseling, including sexual history-taking skills. Participants are taught about the domains of sexual function, female sexual response cycle, types of desire, patient resources, and sexual aids. Feedback following the initial iteration of this workshop was very positive. All participants felt that the experience was an effective use of time, would recommend it to others, and were confident in their ability to apply skills to their clinical practice. Conclusions This interactive workshop led by a multidisciplinary group of providers aims to improve trainee comfort in evaluation and management of female sexual health and menopause. Given the commonplace nature of these topics in primary care and paucity of existing curricula, consideration could be given to the inclusion of a similar educational experience into internal medicine, family medicine and/or obstetrics and gynecology residency programs. Disclosure No.

(003) Taking a Step Back for a (Future) Step Forward: Latent Class Analyses of Vulvo-Vaginal Pain Symptoms

Abstract Introduction Persistent genital pain represents a significant health issue among females, with prevalence ranging from 18.5% for lower genital tract discomfort [2], 20% for chronic dyspareunia [3], and 8.3%-27.9% for vulvodynia [6, 7]. Latent class analyses (LCA) allow the identification of groups of individuals who share common symptom profiles and have been used to subgroup vulvodynia patients based on psychological distress and pain sensitivity [1], spontaneous vs provoked pain and pain comorbidities [8] and based only on comorbid pain conditions [5]. Nonetheless, to our knowledge no study has been conducted investigating clusters of symptom-types commonly reported for persistent genital pain. Objective Test for latent classes (clusters) of individuals based on symptom-types profiles among women with vulvar and/or vaginal pain. Methods Self-reports on sexual and genital health were collected from 2199 women through online questionnaires, as part of a larger study. Efforts were made to recruit a heterogenous sample, with an oversampling of females with genito-pelvic pain. Participants were asked about the presence of specific vulvo-vaginal symptoms. Specifically, eight types of vulvar pain (itching, burning, irritation, needles, cut, electric-shock, bladder weight and urinary urgency) and nine types of vaginal pain (dryness, itching, burning, pulsating, needles, cut, electric shocks, spontaneous spasms and spasms at penetration) were measured. LCA were conducted to identify clusters of individuals sharing similar symptom profiles. Analyses were first done including all women with genital pain, then separately for women experiencing only vaginal and only vulvar pain. Results Of the 2199 participants, 1116 (51%) reported experiencing some type of genital pain, with 52% experiencing vulvar and vaginal pain, 17% only vaginal pain and 31% only vulvar pain. Results from LCA analyses suggest that women experiencing vulvo-vaginal pain could best be grouped into 5 clusters, based on the presence of vulvar and vaginal symptoms (Figure 1). Women with only vaginal pain were grouped into 3 clusters based on vaginal symptoms (Figure 2) and women with only vulvar pain were grouped into 3 clusters based on vulvar symptoms (Figure 3). Across all sets of analyses, clusters were clearly differentiated by specific symptoms. Conclusions Although rates of genital pain are high among females, classification of genito-pelvic pain conditions have been, and still are, a matter of debate. While in the DSM-5 vaginismus and dyspareunia were combined into one diagnostic entity, many clinicians continue referring to them as two distinct conditions, creating incoherence in terminology. In addition, chronic vulvar pain (or Vulvodynia) remains often undiagnosed [7], with women waiting an average of a 6-years before receiving a diagnosis [4]. Our data, obtained from a large sample, allowed us to identify profiles based on an empirical/data driven strategy, and provides an innovative approach to defining genital pain conditions. These results offer a starting point to re-think and discuss how diagnoses currently used to categorize female vulvo-vaginal pain can be improved. Longitudinal studies should be conducted to test whether the current strategy of grouping women with vulvo-vaginal pain provides improved diagnoses, more accurate prognoses, or improves our ability to identify patients who will or will not respond to specific treatments. Disclosure No.

The Novel Use of Bipolar Radiofrequency Microneedling in the Treatment of Lichen Sclerosus.

Lichen sclerosus (LS) is a chronic, distressing, inflammatory process that has a huge impact on quality of life in women. Uncontrolled vulvar LS can lead to chronic symptoms of itching and pain and can lead to anatomic changes, scarring, and elevated risk of cancer. First-line therapy with corticosteroids is often not successful in controlling symptoms, especially over the long term. This is the first study to review the effects of bipolar radiofrequency (RF) with microneedling to treat the vaginal and vulvar symptoms of LS. This retrospective study was initiated due to the recognition of improvement in vulvar skin condition and resolution of lichen sclerosus symptoms in patients who had already failed traditional treatment and underwent radio frequency with microneedling procedures of the vulva, perineum, and perianal regions. Patients were treated with three treatments of bipolar RF and bipolar RF with microneedling four to eight weeks apart. Patient questionnaires were used to assess improvement in the symptoms of LS including itching, tearing of tissue, changes in the appearance and color of tissue, and dryness of skin and mucosa. The data from the questionnaires showed a significant reduction or complete resolution in these symptoms, with 86% of the patients reporting either significant or complete resolution. In the case of itching, which is typically one of the most severe symptoms of LS, 91% of patients reported significant or complete resolution. 87% of patients reported symptom resolution lasting at least six months, with 39% of the patients having results lasting 12 months or more before recurrence. Recurrences can be retreated on an as-needed basis or with annual maintenance therapy consisting typically of just one treatment. Radiofrequency with microneedling treatments for persistent LS showed significant improvement in LS symptoms. As LS is a chronic recurring condition, the treatment protocol resulted in high patient satisfaction for these women who had not experienced these results in terms of amount of symptom resolution or duration of symptom resolution with prior treatments using topical steroid cream or other modalities.

Anxiety and depression among women with newly diagnosed vulvar cancer - A nationwide longitudinal study.

Our objective was to investigate the trajectories of anxiety, depression, emotional and social functioning in women with newly diagnosed vulvar cancer from the time of diagnosis to 12 months after treatment. A further aim was to identify risk factors for high levels of anxiety. PROVE (PROspective Vulvar Cancer Evaluation) is a nationwide longitudinal cohort study investigating quality of life in women with newly diagnosed vulvar cancer by the following validated patient-reported outcome measures at diagnosis, and 3 and 12 months after treatment: The Hospital Anxiety and Depression Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Vulvar module VU34. Mean scores, changes over time and associations were analyzed by generalized estimated equations and log-linear regression models, adjusted for possible confounders. Between 2019 and 2021, 105 (69%) women completed the questionnaires at all three time points. At diagnosis, 42% of the women reported elevated anxiety levels, decreasing significantly to 30% during the first 12 months. Insomnia, persisting vulvar symptoms and high information needs were significantly associated with a high level of anxiety (relative risk [RR] 2.1, 95% CI 1.2-3.7 for insomnia; RR 2.8, 95% CI 1.7-4.6 for vulvar symptoms, RR 2.7, 95% CI 1.5-4.9 for information needs). We found a trend towards a higher level of anxiety in younger women (<65 years: RR 1.5, 95% CI 1.0-2.5). Participants reported a low and stable prevalence of depression (14%) and high social functioning throughout the study period. Women with newly diagnosed vulvar cancer report a high level of anxiety at diagnosis. Despite a significant improvement, anxiety remains widely prevalent during the first year of follow-up. Targeting insomnia, vulvar symptoms and unmet needs may decrease anxiety during surveillance.

1231 Radical Vulvectomy and Reconstruction for Severe, Refractory Crohn's Disease of the Vulva: A Case Report

Abstract Vulval Crohn’s disease (VCD) is rare and can arise from direct infiltration, through fistulae or as non-contiguous lesions, so called metastatic disease. We present a case of a 32-year-old female with severe, refractory vulval Crohn’s disease (VCD), requiring radical vulvectomy and reconstruction. She had a subtotal colectomy for Crohn’s disease 8 years previously, and for one year had experienced vulval swelling and pain associated with perianal fistulae for which she underwent an abdomino-perineal resection. Though she achieved long term remission of her gastrointestinal disease, she continued to experience severe vulval symptoms with recurrent infections and abscesses despite treatment with immunomodulators and biologics over a period of 10 years. She then underwent a radical vulvectomy with bilateral gluteal fold flap reconstruction and skin grafting. She made an uncomplicated post-operative recovery. Histopathology showed active non-caseating granulomatous vulvitis. At 1 year follow up, there were no further disease flares, with significant improvement of her pain. Further plastic surgery is being considered. Our case demonstrates the value of surgical management in refractory VCD to improve symptoms, function and quality of life. Though medical therapy with immunosuppressive agents is recommended as first-line treatment, the course of VCD is unpredictable and often relapses on treatment cessation. VCD may persist for long after remission of gastrointestinal disease and may require more aggressive surgery using a multispecialty approach even in the context of active infective disease.

The impact of limited access of photodynamic therapy during COVID-19 pandemic on patients with vulvar lichen sclerosus.

Stressful situations have an impact on progression of lichen sclerosus. The aim of the study was to investigate fears and complaints of patients with vulvar lichen sclerosus and progression of disease at the beginning of the COVID-19 pandemic. The analysis was based on 103 women with mean age was 64.81 ± 11.36 years divided into two groups. The first one comprised of patients with stabilization of disease during the pandemic with mean age 66.02 ± 10.01 (32-87), while the second one with progression of vulvar symptoms with mean age 63.49 ± 12.66 (25-87). Delay of diagnosis was reported to be a problem for respectively 25.93% of women from both groups. Fear about COVID-19 was described respectively by 57.4% and 55.1%. Stabilization of disease was more frequent in patients after photodynamic therapy before pandemic. Progression of vulvar symptoms and features were observed more in patients who did not conduct PDT previously. All patients from the second group who underwent photodynamic therapy reported disappointment because of no access for continuation of treatment. On the other hand, 81.4% (43 women) regret that have no chance for trying photodynamic therapy. Photodynamic therapy seems to be a method of treatment with longer survival without progression of lichen sclerosus in times of pandemics. There has been no investigation until now about concerns of patients with vulvar lichen sclerosus. Better understanding of problems connected with the pandemic can help medical personnel in taking care of patients with vulvar lichen sclerosus.

CD11 Patch testing in vulval dermatoses

Abstract Patch testing is an important tool in the investigation of patients with vulval dermatoses, with a significant impact on patients with a relevant identifiable allergen. There has been little research conducted in this area, with small studies suggesting a higher rate of positivity in anogenital dermatoses (39–78%) vs. patch testing in female patients generally (35–40%) (Woodruff CM, Trivedi MK, Botto N, Kornik R. Allergic contact dermatitis of the vulva. Dermatitis 2018; 29:233–43). There is also a high rate of clinically relevant results (13–49%) (Vandeweege S, Debaene B, Lapeere H, Verstraelen H. A systematic review of allergic and irritative contact dermatitis of the vulva: the most important allergens/irritants and the role of patch testing. Contact Dermatitis 2023; 88:249–62). The aetiology of this increased rate of allergic dermatitis at this site can be attributed to a number of factors. This includes intrinsic immunological characteristics of the vulval skin, local elements including infection and urine exposure, as well as external behavioural factors. There is a lack of site-specific guidance in light of this propensity of allergic contact dermatitis in vulval dermatoses. This review examined 54 patient records retrospectively at the University Hospital North Durham from 2016 to 2021 and prospectively from July to December 2022 referred for patch testing with vulval symptoms. Forty-eight patients were included with an average age of 51 years. Itch (48%) and discomfort or soreness (28%) were the main symptoms for which patients were referred. The most frequently requested patch test batteries after the British Standard Battery were medicaments, then cortico­st­eroid. The overall positivity of this cohort was 73%, in line with the available literature. The most common allergens were nickel, followed by fragrances. Of the patients with positive patch tests, 48% were relevant. Forty per cent had a partial response on withdrawal of the allergen, and 8% had complete response. Given the psychosocial impact of vulval pruritus and discomfort and the high positivity of patch testing in these patients, further population-based research is warranted to standardize patch testing in vulval dermatoses. Additionally, a low threshold for referral for patch testing should be considered to identify any element of allergic contact dermatitis in patients with recalcitrant vulval symptoms.

LASER treatment in gynaecology –A randomized controlled trial in women with symptomatic lichen sclerosus

ObjectiveAim of our study was to evaluate the therapeutic effect of laser treatment in vulvar lichen sclerosus, mainly the reduction of existing symptoms as itching, burning and pain. We asked about the different outcome by using different application doses. Study designWe conducted a prospective randomized double-blind dose-controlled trial in our dysplasia unit specializing vulvar disorders. 67patients with active LS were included. LS was confirmed by biopsy or by the validated CSS (clinical scoring system of vulvar LS). Computer generated randomization resulted in two groups, each group received a different application dose.(LDG- low dose group, NDG- normal dose group) During the study period of 18 weeks all participants received three laser applications in three subsequent sessions of three weeks. Two follow-ups six and twelve weeks after the first application was performed. At every visit, the participants filled in the VAS (visual analogue scale) for recording the actual vulvar symptoms as itching burning or pain on a range from 0 to 10. ResultsBefore treatment the mean VAS-Score was 4.3 (STD ± 2.4) in the NDG and 5.1(±2.6) in the LDG. After 18 weeks, the mean reduction was −2.4 (±2.3) for NDG and −2.7 (±2.8) for LDG. Four patients (two of each group) reported more pain after than before treatment. Both groups show significant lower VAS-Scores 18 weeks after the treatment than before therapy (p < 0.0001).The reduction of symptoms after 18 weeks between NDG and LDG was not significant (p = 0.6244). ConclusionLaser treatment with the microablative CO2 laser leads to a significant improvement for symptoms of LS.A higher dosage of laser radiation shows no benefit concerning the symptoms. We have not observed any serious adverse events during this study.

(125) Sexual Pain Symptoms in 910 Premenopausal Women with Vulvar Lichen Sclerosus

Abstract Introduction Lichen sclerosus (LS) is an autoimmune inflammatory skin condition primarily affecting the vulva and perianal areas and leading to scarring that can affect sexual function. Most research on symptomatology of LS to date includes predominantly postmenopausal populations and focuses on pruritis, not sexual pain symptoms. Objective This study aims to characterize sexual pain symptoms associated vulvar LS among premenopausal women. Methods A cross-sectional web-based study was conducted in premenopausal women with clinical and/or biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating demographics, characteristics of symptoms, timing and accuracy of diagnosis, and concomitant autoimmune conditions. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 910 met inclusion criteria. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 3% Asian, and 1% Black. The mean age of the population was 36.5 years, ranging from 18-50 years. There was a 4.3-year mean delay in diagnosis, with average age of symptom onset of 27.7 years and average age of diagnosis of 33.2 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.509 (t(805)=16.752, p&amp;lt;0.0001). Most prevalent symptoms were vulvar fissures (68%), dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and labial resorption (61%), with vulvar fissures (49%) and dyspareunia (46%). These symptoms were more common than introital stenosis (34%). Vulvar fissures (41%) and dyspareunia (35%) most often prompted medical attention. Thirty-six percent reported clitoral phimosis and 34% reported decreased clitoral sensation. Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Over 75% of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (54%) or bacterial vaginosis (22%). Most common concomitant autoimmune condition reported was hypothyroidism (10%); which was significantly greater than the general population prevalence (2%) (p&amp;lt;0.0001). Post-hoc analysis indicated no statistical difference between biopsy-confirmed and clinically-diagnosed LS across all demographics and responses. Conclusions Vulvar LS affects sexual function in premenopausal women. LS symptoms in premenopausal women include vulvar fissures, dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. Dyspareunia is present is over two-thirds of premenopausal women with vulvar LS, with vulvar fissures and tearing much more common and bothersome than introital stenosis. Patients are less likely to be affected by or seek medical attention for clitoral phimosis, even though it is present in over one-third of those with LS. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms. Sexual health and function should be a core outcome measure in LS research and addressed in the evaluation and treatment of this condition. Disclosure No

(070) Treatment of Genitourinary Syndrome of Menopause is Beneficial for Lichen Sclerosus Patients

Abstract Introduction Postmenopausal women with Lichen Sclerosus frequently report vulvar symptoms consistent with genitourinary syndrome of menopause (GSM) including pruritus, dyspareunia, or non-provoked pain. Our data revealed not surprising vulvar itching as the most frequently reported symptom of LS, second most frequent was general irritation, followed by vaginal dryness, and vulvar burning. Distinguishing these symptoms from GSM which occurs in 27-84% of postmenopausal women can be problematic. Objective The purpose of this study was to understand the symptoms of postmenopausal women with LS. We specifically surveyed them regarding their symptoms and treatments they had tried including both prescription and over the counter. Methods We interviewed 25 women with biopsy proven LS. This was part of a larger study on the microbiome and genetics of postmenopausal women with LS. Results Our data revealed that while the majority of the women in our study were using standard treatments such as high or medium potency steroid ointments or calcineurin inhibitor, less than 25% reported using hormonal medicines in their vulva (4 of 17), a common treatment for postmenopausal symptoms of vulvar burning, general irritation and dryness; Our data revealed that 50% of the women reported they had used at least more than one prescription or over the counter product to manage symptoms, none of which were hormone related. Conclusions Our data suggests that while these women were treated for their LS, their menopausal symptoms were not addressed. These findings lead us to believe perhaps their menopausal symptoms had been undertreated and that LS symptoms may be difficult to manage exclusively with standard treatments such as steroids and/or calcineurin inhibitors in postmenopausal women. Treatment of GSM with standard recommended treatments is beneficial for LS patients. Disclosure No

(282) Impact of Lichen Sclerosus on Menopausal Women's Sexual Health

Abstract Introduction Lichen sclerosus (LS) is a vulvar dermatosis of unknown origin that affects 1 in 70 women. There is a higher incidence in menopausal women, which may be due to detection bias. LS presents with skin texture changes, hypopigmentation, and scarring. Common symptoms include vulvar burning, pruritus, and dyspareunia. Objective This study was to understand the sexual health experience for menopausal women with LS and was part of a larger study on the microbiome and genetics of menopausal women with LS. Methods We interviewed 25 women with biopsy proven LS and 5 post-menopausal women who do not have LS or any other vulvar symptoms. This was part of a larger study on the microbiome and genetics of postmenopausal women with LS. We specifically surveyed them regarding the impact their diagnosis had on their sexual health. Results The majority (n=10) of the women reported a satisfactory sex life prior to being diagnosed with LS. However, the majority (n=11) of respondents reported that it negatively changed since being diagnosed and most reported their sex life as not being satisfactory (n=8). When asked how their sex life changed women responded with “too uncomfortable at times so hesitant to cause irritation,” “pain, avoidance for intercourse,” “no sex life,” or “no desire no sex.” Unfortunately, the majority (n=10) of the women were not told when they were diagnosed with LS about the possible changes to their sex life. Furthermore, the majority (n=28) were not prescribed medications or had procedures done to improve their sexual health. Conclusions Our study revealed that LS had a negative impact on our participants' sexual health and yet the women were not informed of this or given treatment options. We hope this study will call attention to providers to the need for patient education regarding LS' potential negative effects on women's sexual health. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Scynexis

Current Practices in Brazil on Diagnosis and Management of Women With Vulvodynia.

Vulvodynia (VVD) is a frequent and harrowing condition for which diagnosis and management remain insufficient. Our study aimed to describe and compare vulvovaginal signs and symptoms of Brazilian women with VVD and controls and describe previous medical assessment, past treatments, and vulvar pain relief among women with VVD. This cross-sectional descriptive study included Brazilian women with (n = 151) and without VVD (n = 106). All women were assessed for vaginal infection, vulvar pain intensity by means of a cotton swab test based on a numerical rate scale, and answered the Female Sexual Function Index questionnaire and a structured instrument about current vulvar symptoms. Previous treatments were assessed in the VVD group, and vulvar pain relief achieved with previous treatments was qualified through a 4-point Likert scale. Volunteers were mainly White, with mean age of 30 years. Vulvovaginal signs and symptoms were significantly more frequent in women with VVD (p < .05), and vulvar pain duration was 5.8 (±4) years. More than 50% consulted with three or more physicians, and 49% remained without a conclusive diagnosis. Previous diagnosis and treatment of vulvovaginal infection were often reported by women with VVD. Most of the tried prescriptions were self-reported as providing only low vulvar pain relief. Prolonged duration of vulvar pain, multiple visits to health care professionals, and poor relief of pain are common aspects in the clinical history of women with VVD. In addition to pain, vulvar fissure, edema, erythema, vaginal discharge, and foul odor are common and should be considered to avoid misdiagnosis. Appropriate treatments to VVD are still poorly reported.

Gliflozin (SGLT2 inhibitor) induced vulvitis.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors, or gliflozins, are used as mono or combined therapy in the management of diabetes. Genital infections are the most common reported adverse effect, as a result of induced glycosuria. Cutaneous features of patients experiencing vulval symptoms while on SGLT2 inhibitor therapy have not been clearly described in published literature. We have observed a specific inflammatory vulvitis with psoriasiform features in patients taking SGLT2 inhibitors, related to candidiasis in most cases. Demographic and treatment outcomes of 11 patients with characteristic inflammatory changes after starting SGLT2 inhibitors were extracted from electronic records. Ninety-one percent (n = 10) had candidiasis, treated with fluconazole. Six (54.5%) were able to continue SGLT-2 inhibitors through the addition of topical treatments, but five patients had to discontinue the drug. SGLT2 inhibitors can result in characteristic inflammatory vulvitis. Treatment with topical agents and single-dose antifungals may allow patients to continue their therapy to achieve improved glycemic control. In resistant cases, discontinuation of the drug is necessary. We highlight this effect so that early treatment can be initiated to alleviate symptoms and recognition of underlying cause.

Vulvar Pruritus in Postmenopausal Diabetic Women With Candidiasis Secondary to Sodium-Glucose Cotransporter Receptor-2 Inhibitors.

Vulvar pruritus with external rash in postmenopausal women on sodium-glucose cotransporter receptor-2 inhibitors may indicate vulvovaginal candidiasis, which requires early yeast culture for prompt diagnosis and management. Objective/Purpose We present a case series of recurrent vulvovaginal candidiasis (RVVC) secondary to sodium-glucose cotransporter receptor-2 (SGLT2) inhibitor-induced glucosuria in postmenopausal women that resulted in extensive vulvar skin involvement. Materials and Methods We describe 5 cases of RVVC presenting primarily with vulvar pruritus and external rash, in type 2 diabetic, postmenopausal women on SGLT2 inhibitor therapy. This work was exempt from institutional review board approval in compliance with the university guidelines for determining human subject research. All patients consented to the use of pictures for educational and research purposes. Results All patients developed RVVC, with vulvar cultures positive for Candida albicans and resolution of symptoms after treatment with oral fluconazole. All patients presented primarily with severe vulvar pruritus that developed after beginning treatment with SGLT2 inhibitors (range: 4 wk–16 mo). Given the intermittent nature of symptoms, variable degree of activity at presentation, lack of vaginal discharge, atypical population, and extensive skin involvement, RVVC was not considered initially. Three patients were misdiagnosed with lichen sclerosus and treated with topical steroids, which may have allowed for disease progression. Two patients were prescribed topical estrogen creams for presumed vaginal atrophy. One patient was misdiagnosed with improper vulvar hygiene and neuropathic itch. Because of these diagnostic missteps, 4 patients endured symptomatically for extended periods (range: 2–6 years) without adequate treatment. Four patients have discontinued their SGLT2 inhibitor, all with resolution of vulvar symptoms. Conclusions Postmenopausal, diabetic women taking SGLT2 inhibitors presenting with vulvar pruritus and rash require early evaluation for RVVC to prevent misdiagnoses and need for diabetic medication alterations.

Vulvovaginal candidiasis: Epidemiology, treatment and prevention strategies

Vulvovaginal candidiasis (VVC) is a commonly encountered clinical condition. At least three-fourth women experience one episode of VVC in their lifetime. In India, the prevalence of VVC is 10 to 35%. Laboratory methods often supplement clinical diagnosis. VVC should be confirmed with culture and other investigative techniques, especially in complicated and recurrent cases. Topical and intravaginal azoles remain the mainstay of therapy. In women who have predisposing risk factors or develop recurrent VVC, oral antifungal agents are used. Topical steroids may be used in women having vulvar symptoms along with pruritus. Pregnancy is a significant risk factor. Intravaginal azoles remain the standard of treatment and can be offered from the second trimester onwards. The emergence of non-albicans species has caused difficulties in the management of VVCs. Thus, all women with vaginal discharge should be correctly diagnosed to tailor the therapy.

Vaginal Leptothrix: An Innocent Bystander?

Leptothrix are long bacteria of rare occurrence; although these bacteria have been implicated in causing vaginal symptoms identical to candidiasis, studies on prevalence and effect on overall vaginal health are lacking. In this study, we evaluated data of women referred to a private clinic for treating vulvovaginal symptoms (n = 1847) and reassessed data of our previous and ongoing studies (n = 1773). The overall rate of leptothrix was 2.8% (102/3620), and the mean age of affected women was 38.8 ± 10.65 years (range 18−76). The majority of the women with leptothrix had normal vaginal flora (63.7% [65/102]). Leptothrix was associated with a higher risk of candidiasis (relative risk (RR) 1.90, 95% confidence interval (CI) 1.1600–3.1013; p = 0.010) and a lower risk of bacterial vaginosis (RR 0.55, 95% CI, 0.3221–0.9398; p = 0.029) and cytolytic vaginosis (RR 0.11, 95% CI, 0.0294–0.4643; p = 0.002). No cases of trichomoniasis were observed. Human immunodeficiency virus infection increased the risk of leptothrix (RR 3.0, 95% CI, 1.6335–5.7245; p = 0.000). Among the women evaluated for vulvovaginal symptoms, 2.4% (45/1847) had leptothrix, and in 26.7% (12/45), leptothrix was considered the causative entity. This study suggests that leptothrix occurrence is rare; it remains unresolved if it can be a cause of vulvar symptoms.

Sexual Pain Symptoms in Premenopausal Women with Vulvar Lichen Sclerosus

ABSTRACT Introduction Lichen sclerosus (LS) is a chronic, inflammatory skin condition that primarily affects the anogenital epithelium in women. Vulvar LS has historically been regarded as a condition of premenarchal girls and postmenopausal women, overlooking women of reproductive age. Although vulvar LS characteristically presents with pruritis, specialists in LS have clinically observed that premenopausal women often present with dyspareunia related to introital tearing and vulvar skin changes. Objective This study aims to characterize the clinical presentation of vulvar LS among premenopausal women related to sexual pain. Methods A cross-sectional web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, as well as timing and accuracy of diagnosis. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 503 met inclusion criteria of biopsy confirmed LS and premenopausal status. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 2% Asian, and 1% Black. The mean age of the population was 37 years, ranging from 19-50 years. There was a 4-year delay in diagnosis, with an average age of symptom onset of 27 years and average age of diagnosis of 32 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.487 (t(455)=14.184, p&amp;lt;.0001). Most prevalent symptoms were dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and decreased clitoral sensation (35%). Symptoms reported as most affecting the individual were dyspareunia (44%), tearing with intercourse or vaginal insertion (39%) and pruritis (25%), followed by decreased clitoral sensation (13%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%), and tearing with intercourse or vaginal insertion (26%). Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Most prevalent skin changes included hypopigmentation (81%), vulvar fissures (72%), labial resorption (60%), clitoral phimosis (39%), and vaginal stenosis (37%), with vulvar fissures affecting the individual the most (48%) and prompting medical attention (39%). Sixty-six percent of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Conclusions Vulvar LS affects premenopausal women and often causes skin changes related to sexual function. This condition is often misdiagnosed as vulvovaginal candidiasis, leading to a delay in diagnosis of 4 years, which is consistent with existing literature. LS symptoms in premenopausal women related to sexual function and pain include dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. These symptoms may be more concerning to premenopausal women, who are more likely to be sexually active, than the classic symptoms of vulvar pruritis found predominantly in postmenopausal women. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms and sexual pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; Part-time employee of Dare Bioscience, has received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects, and is a consultant for Ipsen, SST, and AMAG

SIIV position paper: clinical approach to vulval diseases. Need for quality standards.

This paper summarizes the position of the Italian Society of Vulvology on the clinical approach to vulval disease. A thorough history (general medical, gynaecological, and vulval history) is essential for a successful and fruitful vulvological examination. Characteristics of pruritus (itch) and pain, that are the two main vulval symptoms, should be collected and reported with precision, according to duration, temporal course, location, provocation, and intensity. Physical examination must consider both the general condition of the patient and the specific vulval region, that must be examined following a standardized methodology. The physical examination of the vulva is carried out with naked eye and adequate natural or halogen lighting. The subsequent use of instrumental magnification can be considered on particular parts of skin/mucosa, already highlighted with the first inspection. Also, palpation is essential, allowing to appreciate physical features of vulval lesions: consistency, surface, soreness, adherence to underlying plans. Finally, the five-step approach of the International Society for the Study of Vulvo-vaginal Disease about Terminology and Classification of Vulvar Dermatological Disorders (2012) is summarized. A vulval biopsy may be useful in the following situations: when clinical diagnosis is uncertain, lesion not responding to treatment; histologic confirmation for a clinical diagnosis and exclusion or confirmation of a suspected neoplastic intraepithelial or invasive pathology.

A rare case of recurrent group A streptococcal vulvovaginitis in a premenopausal woman.

A rare case of recurrent group A streptococcal vulvovaginitis in a premenopausal woman.