Effects of topical estrogen therapy on the vaginal microcirculation in women with vulvovaginal atrophy.

AIMS: This study aims to assess vaginal wall angioarchitecture and function in women with vulvovaginal atrophy (VVA) and determine the effect of topical estrogen on the vaginal microcirculation. MATERIALS AND METHODS: In this prospective observational study, incident dark field imaging was used to assess the vaginal microcirculation. In patients with VVA, measurements were performed before and after treatment with topical estrogen and compared to measurements performed in women without VVA. Vaginal angioarchitecture was studied by assessing microcirculatory architecture and capillary tortuosity scores at four regions of the vaginal wall. In addition, the capillary density and microvascular flow index (MFI) were obtained. RESULTS: Seventeen women were included in this study. Of these, eight women were diagnosed with VVA and nine women were considered healthy controls. Significant differences were observed between groups with regard to microcirculatory architecture scores. The architecture of the microvasculature in women with VVA was characterized by the appearance of a vascular network without capillary loops, whereas an array of capillary loops was predominantly seen in women without VVA. After estrogen treatment, no difference in architecture scores between patients and healthy controls was observed. Capillary tortuosity, capillary density, and MFI were similar in both groups before and after estrogen treatment. CONCLUSIONS: The architecture of vaginal microvasculature is altered in patients with VVA. In case of similar vascular architecture, capillary tortuosity and density seem to be comparable. Treatment with topical estrogen results in restoration of the angioarchitecture.

The Effect of Vaginal Oestriol Cream on Subjective and Objective Symptoms of Stress Urinary Incontinence and Vaginal Atrophy: An International Multi-Centre Pilot Study.

AIM: Subjectively and objectively assess stress urinary incontinence (SUI) symptoms before and after topical oestrogen therapy. METHODS: A prospective study was performed in 3 centres in South-Africa, Australia and the Netherlands. Postmenopausal women with SUI were treated with topical oestriol cream for 6 weeks. The primary subjective outcome was the Patient's Global Impression of Improvement (PGI-I) scale. The primary objective outcome was vaginal pH. Secondary subjective outcomes were: the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form, the Incontinence Impact Questionnaire, the Urogenital Distress Inventory (UDI-6) and the most bothersome symptom approach. Secondary objective outcome was the erect cough pad test. Compliance was scored. RESULTS: A total of 68 women were enrolled. Half of the participants reported improvement on the PGI-I scale after treatment. Vaginal pH was significantly lower after treatment (median 5.3 (interquartile range (IQR) 4.5-6.0) vs. 5.0 (4.4-5.4), p = 0.002). Improvement on the UDI stress domain was observed (p = 0.01). No statistically significant differences were found in the other subjective outcomes. Baseline and repeat cough pad tests demonstrated a wide variation with no significant difference. Compliance was high (median 100 (IQR 83-100%)). CONCLUSION: Topical oestriol cream during 6 weeks improved quality of life and vaginal pH but no other objective measures of incontinence.

Focal depth measurements of the vaginal wall: a new method to noninvasively quantify vaginal wall thickness in the diagnosis and treatment of vaginal atrophy.

OBJECTIVE: The aim of the study was to evaluate if vaginal focal depth measurement could be a noninvasive method to quantify vaginal wall thickness. METHODS: Postmenopausal women undergoing topical estrogen therapy because of vaginal atrophy (VA) were recruited. VA was diagnosed based on the presence of symptoms and vaginal pH at least 5.5. The control group consisted of women above 40 years without VA. Focal depth measurements were performed before and after treatment using the Cytocam-Incident Dark Field device assessing the distance between the subepithelial microcirculation and the epithelial surface. Measurements were performed before and after treatment in the intervention group and at two different time points in the control group. Vaginal pH was measured. Symptoms were evaluated using the most bothersome symptom approach. RESULTS: Eight women with VA and nine controls were included. Pretreatment median focal depth was not significantly different between both groups. Pretreatment focal depth more than doubled after a median of 7 weeks of topical estrogen treatment (80 µm [interquartile range 80-120 µm] vs 220 µm [148-248 µm], P = 0.02), whereas the measurements in the control group did not change. Pretreatment vaginal pH differed between both groups (5.5 vs 5.1, respectively, P < 0.01). Vaginal pH did not change after treatment. CONCLUSIONS: Using in vivo microscopy we introduced a new noninvasive measure of vaginal wall thickness. A significant increase in vaginal focal depth was observed in participants with VA treated with topical estrogens. This innovative measurement of vaginal wall thickness could become the preferred objective measure to evaluate treatment effect. Moreover, it has great potential for other applications in the field of urogynecology.

Vaginal microcirculation: Non-invasive anatomical examination of the micro-vessel architecture, tortuosity and capillary density.

AIM: To describe the vaginal microcirculatory architecture and capillary density parameters using sidestream dark-field imaging (SDFI), and determine feasibility and reliability of this method. METHODS: In nine healthy female volunteers SDFI measurements were performed at two different time points in the luteal phase of the menstrual cycle. Non-invasive tissue micro-angioarchitecture and vaginal capillary density measurements were assessed independently by two observers. Agreement was expressed with mean differences between the measurements of both observers and the limits of agreement. Inter- and intra-observer agreement was quantified with the intra-class correlation coefficient (ICC). RESULTS: Vaginal microcirculatory assessment with the SDFI device was easy in use, painless and well accepted by the participants. Morphologically, the vaginal microcirculation revealed an array of single hairpin-shaped capillary loops distributed homogeneously across an imaged tissue segment. The intra-observer assessment of the capillary density measurements (comparing two measurement time points of one observer) showed good agreement with an ICC ranging from 0.62 to 0.85. The inter-observer assessments of the capillary density measurements (comparing assessments of two observers at one time point) revealed very good agreement, with small differences between observers and an ICC of more than 0.9. CONCLUSIONS: This is the first report on both microcirculatory architecture and quantitative microcirculatory parameters of the vagina with the use of SDFI. Micro-vessels of the vagina show a recognizable pattern in our study population of young, healthy women. SDFI gives a reproducible assessment of the vaginal microcirculation offering the researcher a wide field of applications.

The effects of vaginal prolapse surgery using synthetic mesh on vaginal wall sensibility, vaginal vasocongestion, and sexual function: a prospective single-center study.

INTRODUCTION: Vaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction. AIM: We aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP. METHODS: A prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi-probe. MAIN OUTCOME MEASURES: The combi-probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse-generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale-Revised, and Subjective sexual arousal and affect questionnaire). RESULTS: Sixteen women were included, 14 completed the 6-month follow-up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected. CONCLUSIONS: In women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential.

First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing.

BACKGROUND: This study was conducted to describe the first experiences with hysterosalpingo-foam sonography (HyFoSy) as a first step routine office procedure for tubal patency testing. METHODS: A prospective observational cohort study was started in a university affiliated teaching hospital. In 2010, 73 patients with subfertility and a low risk of tubal pathology were examined. A non-toxic foam containing hydroxymethylcellulose and glycerol was applicated through a cervical applicator for contrast sonography (HyFoSy). Tubal patency was determined by transvaginal ultrasonographic demonstration of echogenic dispersion of foam in the Fallopian tube and/or the peritoneal cavity. Only in case patency could not be demonstrated, a hysterosalpingography (HSG) was performed as a control. RESULTS: In 67 out of 73 (92%) patients, a successful procedure was performed. In 57 out of 73 (78%) cases, there was no further need for a HSG. In five patients (5/73; 7%) tubal occlusion was confirmed by HSG and in five patients (5/73; 7%) there was discordance between HyFoSy and HSG. Of 73 patients, 14 (19%) conceived within a median of 3 months after the procedure. CONCLUSIONS: HyFoSy is a successful procedure to demonstrate tubal patency as a first step office procedure.