Using advanced analytics to help identify women who are more likely to have a severe subjective experience of vulvovaginal atrophy: a modeling study.

OBJECTIVE: To develop a model to identify women likely to be severely impacted by vulvovaginal atrophy (VVA), based on their experience of symptoms and non-clinical factors. METHODS: Multivariate statistics and machine-learning algorithms were used to develop models using data from a cross-sectional, observational, multinational European survey. A set of independent variables were chosen to assess subjective VVA severity and its impact on daily activities. RESULTS: A final composite model was selected that included three categories of variables: clinical severity, patient demographics/clinical characteristics and Day-to-Day Impact of Vaginal Aging (DIVA) variables related to emotion/mood, impact on lifestyle and frequency of sex. The model accurately classified 71% of women. Three DIVA variables (feeling bad about yourself, desire/interest in sex, physical comfort related to sitting) explained much of the variation in the dependent variable of the model. Over 90% of the impact of VVA relates to certain psychosocial and behavioral aspects that can be identified without the need to consider physical signs/symptoms. CONCLUSION: Non-clinical factors can contribute significantly to the overall VVA burden.Questions used in developing the composite model could form the basis of an instrument to help screen women prior to clinical consultation and improve VVA management.

Plurigin Ovules and Plurigin Solution in the Treatment of Vulvovaginal Atrophy in Menopausal Women: A Retrospective Monocentric Observational Study.

Background and Objectives: Vulvovaginal atrophy (VVA) is a condition that affects a large number of women and can significantly impact their quality of life. While several treatments are currently available for VVA, there are potential risks associated with their use. Non-hormonal medical devices have been developed to treat VVA, offering a potential alternative to traditional hormone-based therapies. This study aimed to evaluate the safety and efficacy of the combined treatment with two medical devices, Plurigin Ovules and Plurigin Solution, used as an adjuvant in the treatment of VVA. Materials and Methods: This is a retrospective, observational study. Data were collected from medical records of all patients who received the combination treatment of both medical devices as part of normal clinical practice for the treatment of VVA. The performance of the medical devices was analyzed using the THIN Prep. A comprehensive physical examination and gynecological evaluation were conducted before the initiation of treatment (day 0), as well as at follow-up 1 (day 90), follow-up 2 (day 180), and follow-up 3 (day 270). Data analysis included descriptive analysis and statistical tests. Results: The study included 76 women (mean age: 59 years). At follow-up 3, 61% of the respondents demonstrated improved THIN Prep results and symptom resolution (p < 0.001; CI [0.5003, 0.7197]). Moreover, the percentage of patients reporting dyspareunia, burning, and irritation decreased over the course of the study, with the majority of patients reporting no symptoms at follow-up 3. Conclusions: The use of Plurigin Ovules plus Plurigin Solution may be an effective treatment option for VVA, improving vaginal health, alleviating symptoms, and improving sexual function, leading to improved quality of life for women suffering from this condition. However, the study has limitations, such as its retrospective nature, and further studies are needed to confirm the efficacy and safety of these devices.

An online survey on coping methods for genitourinary syndrome of menopause, including vulvovaginal atrophy, among Japanese women and their satisfaction levels.

BACKGROUND: This study aimed to explore the current situation and existing issues regarding the management of vulvovaginal atrophy (VVA) or the genitourinary syndrome of menopause (GSM). A nationwide web-based questionnaire survey was conducted among 1,031 Japanese women aged 40 years or older. MATERIALS AND METHODS: Eligible women were asked to complete a questionnaire about how they dealt with their symptoms and how satisfied they were with their coping methods. RESULTS: Of those highly conscious of their GSM symptoms (n = 208; 20.2%), 158 had sought medical consultation (15.3%), with only 15 currently continuing to seek consultation (11.5%). Of the specialties consulted, gynecology was the most frequently consulted (55%). Furthermore, those unwilling to seek medical consultation despite their symptoms accounted for the greatest proportion (n = 359; 34.8%), with 42 (23.9%) having never sought consultation. Topical agents, e.g., steroid hormone ointments/creams, were the most frequent treatments provided by the clinics (n = 71; 40.3%), followed by oral and vaginal estrogens (n = 27; 15.5%), suggesting that estrogen therapy was not the first choice of treatment at the clinics. While 65% of patients treated at the clinics reported satisfaction with the treatments, this was inconsistent with the fact that many were reported to have remained untreated and very few continued with treatment. CONCLUSIONS: Survey results suggest that GSM, including VVA, remains underdiagnosed and undertreated in Japan. Medical professionals should deepen their understanding of GSM and raise their level of care to select the appropriate treatment for the condition.

Vaginal epithelial histology before and after fractional CO2 laser in postmenopausal women: a double-blind, sham-controlled randomized trial.

BACKGROUND: Postmenopausal vaginal symptoms affect over 60% of women and may substantially impact a woman's quality of life. Since 2012, fractional CO2 laser has been suggested as a treatment for this indication. Structural assessment of vaginal epithelium using microscopic biopsy examination has been used as a primary outcome measure and surrogate determinant of success of vaginal laser in previous clinical studies. OBJECTIVE: This study aimed to report the effects of laser compared with sham treatment on human vaginal epithelium from postmenopausal women using microscopic examination of tissue biopsies. STUDY DESIGN: This single-center double-blind, sham-controlled randomized controlled trial was performed in a tertiary hospital in Sydney, Australia. A total of 49 postmenopausal women who were symptomatic of at least 1 vaginal symptom (vaginal dryness, burning, itching; dyspareunia; or dryness) were randomized to either laser or sham treatment. For this nested histologic study, participants had a pre- and post-treatment vaginal wall biopsy collected. Biopsy samples were analyzed by 3 independent specialist gynecologic pathologists and categorized as Type 1 (well-estrogenized), 2 (poorly estrogenized), or 3 (combination) mucosae. Other outcomes assessed included symptom severity (visual analog scale for symptoms including most bothersome symptom, and Vulvovaginal Symptom Questionnaire) and Vaginal Health Index. Prespecified secondary analyses of data were performed. Categorical data were analyzed using the Pearson chi-square test (or Fisher exact test if <5 in any category) or related-samples McNemar test for paired nonparametric data. Nonparametric, continuous variables were assessed using Wilcoxon signed-rank test or Mann-Whitney U test, and parametric variables with t test or 1-way analysis of variance as appropriate. All analyses were performed using SPSS software version 26.0 (IBM Corp, Armonk, NY). RESULTS: There was no significant difference in microscopic features of vaginal epithelium following laser or sham treatment (P=.20). Further subgroup analyses of age, menopause type, duration of reproductive life, time since menopause and BMI, still demonstrated no significant difference between laser and sham groups in histological category of vaginal epithelium. Microscopic features at pre-treatment vaginal biopsy were Type 1 in 27% (13/49). There was no significant difference in VAS score for overall vaginal symptom between those classified as Type 1 vs. Type 2/3 (VAS score overall: Type 1 vs. Type 2/3, (48.1 [95% CI 27.0, 69.2] vs. 61.5 [95% CI 49.8, 73.3]; P=.166). CONCLUSION: Data from this double-blind, sham-controlled randomized controlled trial demonstrate that fractional CO2 laser and sham treatment have a comparable histologic effect on vaginal tissue that is not significantly different. Fractional CO2 laser is not significantly different from sham treatment and should not be recommended for clinical use for postmenopausal vaginal symptoms.

Vulvovaginal Symptoms in a Postmenopausal Woman: A Case Study.

A postmenopausal female patient was suffering from vulvovaginal symptoms such as dryness and irritation, which were affecting her relationship with her partner and her overall quality of life. The patient was instructed to apply an estriol 0.1% vaginal ointment (PCCA Ellage Anhydrous Vaginal) for a duration of three months. The safety and efficacy of the compounded treatment were evaluated using an online data collection form, which included the validated Vulvovaginal Symptom Questionnaire. Post-treatment results show that the vulvovaginal symptoms were no longer bothersome, and that the patient's relationship was no longer affected. There were no reports of undesirable effects as a result of the compounded treatment. This case study reinforces the benefits and convenience of using topical hormone replacement therapy in postmenopausal women.

Validation of the Vulvovaginal Symptom Questionnaire in Turkish women with genitourinary syndrome of menopause.

OBJECTIVE: This study aims to psychometrically validate the Turkish version of the Vulvovaginal Symptom Questionnaire (VSQ). METHODS: Postmenopausal women with and without genitourinary syndrome of menopause (GSM) were included as the target population and the control group. Psychometric properties were validated both for sexually active (21 items) and passive women (16 items). Several a priori hypotheses were formulated to assess construct validity. Scores of GSM-Assessment Tool, Female Sexual Function Index, Michigan Incontinence Severity Index, Female Genital Self-Image Scale, and Menopause Rating Scale and their correlation with VSQ scores were compared. RESULTS: A total of 242 postmenopausal women were included. The VSQ showed good internal consistency with a Cronbach alpha coefficient of 0.822 (0.800-0.821) and 0.873 (0.853-0.870) in sexually active and passive women, respectively. Originally proposed model (4-factor model, n = 162) showed adequate fit in women with active sexuality and the 3-factor model (n = 242) showed moderate fit. The test-retest reliability was good for symptoms, emotions, and life impact subscales (intraclass correlation coefficient [ICC]: 0.846, 0.835, and 0.755, respectively) and moderate for sexual impact subscale (ICC: 0.643). More than 75% of hypotheses were confirmed. CONCLUSIONS: Our study shows successful cross-cultural adaptation and validation with sufficient psychometric properties for VSQ to be used in Turkish postmenopausal women with GSM.

Vaginal foreign bodies in children: a single-center retrospective 10-year analysis.

OBJECTIVE: To evaluate the clinical features and outcome in girls with a vaginal foreign body. METHODS: The clinical data of 97 girls with a vaginal foreign body were collected between 2010 and 2020. The descriptive analysis was used to summarize the clinical characteristics. RESULTS: The patients were aged between 1.5 and 14.8 years, and the age of peak incidence was shown to be 3-10 years, which accounted for 88% of the cases. Blood-stained vaginal discharge or vaginal bleeding was the most common symptom (48%). The most common foreign bodies were small hard objects (57%), followed by bits of cloth or toilet tissue (22%). The patient whose foreign object was a disk battery had the most severe symptoms. When an injury of the vaginal mucosal was suspected, antibiotics were used to prevent infection, with full recovery of all patients without any additional treatment after removal of the foreign object. CONCLUSION: If there is no damage to the vaginal mucosa, no additional treatment is needed after the foreign body is removed. When a vaginal foreign body is suspected to be a battery, emergency surgery is needed to prevent further damage.

Graft-versus-host disease in the female genital tract: a prospective cohort study.

BACKGROUND: Graft-versus-host disease (GVHD) is the main complication of allogeneic hematopoietic stem cell transplantation (HSCT). GVHD in the female genital tract can cause sinusorrhagia, dyspareunia, synechia, and even complete vagina occlusion. PURPOSE: This prospective study aimed to evaluate the clinical characteristics and effects of preventive and prompt treatment for genital GVHD in females undergoing HSCT (n = 40). RESULTS: Genital GVHD was diagnosed in 11 of 40 patients (27.5%), and the most common complaint was vaginal dryness (54.6%). The majority of patients (63.6%) presented mild genital GVHD (clinical score 1), with interlabial fissures and lichen-like lesions, while a minority of patients (9.1%) presented advanced genital GVHD (clinical score 3) with the fusion of the small and large lips. The median time of onset of genital GVHD signs was 10 months after HSCT, concomitant with GVHD in the skin and oral cavity. Personalized and topical therapy was effective in most cases (81.8%), and no patient required surgical intervention. CONCLUSION: We confirmed that female genital GVHD affects approximately one-third of females undergoing HSCT, highlighting the importance of periodic gynecological monitoring for early detection and treatment to improve care for these females.

Efficacy of CO2 laser treatment in postmenopausal women with vulvovaginal atrophy: A meta-analysis.

OBJECTIVE: To explore the efficacy of CO2  laser treatment in postmenopausal women with vulvovaginal atrophy. METHOD: PubMed, Embase, Cochrane Library and Web of Science were searched to June 9, 2020. Prospective studies on the efficacy of CO2  laser treatment were included. Two researchers independently reviewed articles and extracted data. Heterogeneity test was conducted for each outcome indicator. Sensitivity analysis was performed in all models. RESULTS: Twelve articles including 459 participants were enrolled. Compared with baseline, vaginal health indeices (VHIs) were significantly higher at the 1-, 3-, 6-, and 12-month follow ups (P < 0.001). For VVA severity, the visual analog scale scores for vaginal dryness at 1-, 3-, 6-, and 12-month follow-ups (P < 0.050), vaginal burning, itching, and dysuria at 1-month follow up (P < 0.001), and dyspareunia at 1-, 3-, 6-, and 12-month follow-ups (P < 0.001) were all significantly lower. For FSFI, total scores at 1-, 3-, 6-, and 12-month follow ups (P < 0.001), and the scores in desire, arousal, lubrication, orgasm, satisfaction, and pain at 1-month follow up (P < 0.050) were all significantly higher. For quality of life, the PCS12 and MCS12 scores were all significantly higher (P < 0.050) at the 1-month follow up. CONCLUSION: CO2  laser treatment may be effective for postmenopausal women with VVA symptoms in improving quality of life and sexual function.

Acceptability and efficacy of vaginal self-sampling for genital infection and bacterial vaginosis: A cross-sectional study.

BACKGROUND & AIM: Screening for genital infection (GI) such as bacterial vaginosis (BV) and yeast infection, for sexually transmitted infection (STI), and for asymptomatic carriage of group B streptococcus (GBS) in pregnant women are common reason for medical appointments. The diagnosis and control of GIs, STIs, and GBS are major issues, for fertility and overall well-being of affected women. Conventional testing is performed using vaginal/cervical classical sampling (VCS); this procedure requires pelvic examination performed by health care professionals which raises concerns among women. Vaginal-self-sampling (VSS), as an alternative to VCS, might capture more women. The aim was first to show non-inferiority of VSS compared with VCS to screen for GIs, STIs, and GBS; second to determine the feasibility of VSS. METHODS: VSS and VCS from 1027 women were collected by health care professionals and simultaneously carried out on each patient. GIs, STIs, and GBS were systematically screened in both paired VSS and VCS samples. Non-inferiority of VSS compared with VCS was assessed using z statistic for binomial proportions. RESULTS: Prevalence of GIs were 39.7% using VSS and 38.1% using VCS (p = 0.0016). Prevalence of STIs was 8.5% (VSS) vs 8.1% (VCS) (p = 0.0087). Prevalence of GBS was 13.4% (VSS) and 11.5% (VCS) (p = 0.0001). Most participants (84%) recommended the use of VSS. CONCLUSIONS: This study shows that VSS was not inferior to VCS for the detection of GIs, STIs, and GBS. This study provides evidence that VSS can be used as a universal specimen for detection of lower genital tract infections in women. STUDY IDENTIFICATION NUMBER: ID-RCB 2014-A01250-4.

Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial.

BACKGROUND: We aimed to evaluate the effects of different therapeutic options to prevent the evolution of vaginal stenosis after pelvic radiotherapy in women with cervical cancer. METHODS: open-label randomized clinical trial of 195 women, stage I-IIIB, aged 18-75 years, using topical estrogen (66), topical testosterone (34), water-based intimate lubricant gel (66), and vaginal dilators (29) to assess the incidence and severity of vaginal stenosis after radiotherapy at UNICAMP-Brazil, from January/2013 to May/2018. The main outcome measure was vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE) scale and percental changes in vaginal volume. The women were evaluated at four different times: shortly after the end of radiotherapy, and four, eight, and 12 months after the beginning of the intervention. Statistical analysis was carried out using Symmetry test, Kruskal-Wallis test and multiple regression. RESULTS: the mean age of women was 46.78 (±13.01) years, 61,03% were premenopausal and 73,84% had stage IIB-IIIB tumors. The mean reduction in vaginal volume in the total group was 25.47%, with similar worsening in the four treatment groups with no statistical difference throughout the intervention period. There was worsening of vaginal stenosis evaluated by CTCAE scale after 1 year in all groups (p < 0.01), except for the users of vaginal dilator (p = 0.37). CONCLUSIONS: there was a reduction in vaginal volume in all treatment groups analyzed, with no significant difference between them. However, women who used vaginal dilators had a lower frequency and severity of vaginal stenosis assessed by the CTCAE scale after one year of treatment. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials, RBR-23w5fv . Registered 10 January 2017 - Retrospectively registered.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy.

INTRODUCTION: It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy. AIM: To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions. MATERIALS AND METHODS: Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA. RESULTS: The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment. CONCLUSIONS: The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

Tubulosquamous Polyp of the Vagina: Misplaced Skene's Glands Analogous to the Male Prostate.

Tubulosquamous polyp (TSP) of the vagina is a rare and benign lesion, best considered along the spectrum of lesions derived from Skene's glands, the female counterpart of male prostatic glands. It is likely underdiagnosed and represents a challenging diagnosis if one is unfamiliar with this entity. We present an illustrative case of TSP occurring as an upper vaginal wall nodule of a 75-year-old woman, with characteristic morphology and broad immunophenotype. It should be suspected in postmenopausal women with a polyp that demonstrates biphasic squamous and glandular components, which show a prostatic immunophenotype.

Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review.

BACKGROUND: Vaginal stenosis (VS) is a common side effect of pelvic radiotherapy for gynecological cancer in women. It has a high incidence variability, likely due to unstandardized and subjective assessment methods. Furthermore, even though the worldwide standard treatment for VS is vaginal dilation, low compliance rates have been noted. AIM: To evaluate the parameters used to diagnose VS and to assess whether the lack of an objective measure of VS hampers vaginal dilator use. METHODS: A systematic review in accordance with the PRISMA reporting guidelines was conducted. PubMed, EMBASE, and Web of Science databases were searched. Randomized trials and prospective, retrospective, and cross-sectional studies published from January 2011 to February 2020 were included. OUTCOMES: The main outcome of this study was a review of the published literature on assessment methods for VS and compliance to vaginal dilator use. RESULTS: Of the 28 articles obtained, only 7 used objective methods to measure the vaginal volume. 3 studies have demonstrated patient's concern with VS development and showed a high compliance to dilator use, whereas others reported several barriers to dilator use. CLINICAL IMPLICATIONS: Lack of an objective assessment method can be a predisposing factor for uncertain VS incidence rates and impair compliance to vaginal dilator therapy, leading to long-term VS and sexual dysfunction. STRENGTHS & LIMITATIONS: This is the first systematic review on the heterogeneity of VS evaluation methods and compliance to vaginal dilator use. All studies were comprehensively evaluated by 2 reviewers. The limitations included the heterogeneity of the study designs and the unstandardized criteria used to classify stenosis or to evaluate compliance to dilator use. Although 3 well-known databases were used, the inclusion of more data sources could have increased the number of publications included in this review. CONCLUSION: VS is frequently diagnosed using subjective parameters. Few unstandardized objective methods are used to evaluate this condition. Regarding compliance to vaginal dilator use, there was a high dropout rate during follow-up and no consensus on starting time or ideal usage. Haddad NC, Soares Brollo LC, Pinho Oliveira MA, et al. Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review. J Sex Med 2021;18:493-514.

The International Society for the Study of Vulvovaginal Disease Vaginal Wet Mount Microscopy Guidelines: How to Perform, Applications, and Interpretation.

OBJECTIVES: The aims of the study were to assess the available literature concerning the indications, performance, technique, and classification of wet mount microscopy (WMM) and to establish evidence-based recommendations. METHODS: Literature review from the main scientific databases was performed by the ad hoc "Vaginitis and Microbiome Committee" of the International Society for the Study of Vulvovaginal Disease. The document was approved by the executive council and membership of the International Society for the Study of Vulvovaginal Disease. RESULTS: Available data are limited and usually of low level of evidence. Nevertheless, it shows that WMM is capable of reducing misdiagnosis, overtreatment, and undertreatment of vaginal conditions. It has an excellent performance for the diagnosis of bacterial vaginosis and variable performance for trichomoniasis and candidiasis. It is the gold standard for aerobic vaginitis/desquamative inflammatory vaginitis. Currently, there is no recommendation to use WMM in the screening of asymptomatic women.The use of phase contrast is recommended to improve performance and reproducibility. Sampling location, devices, and technique have an impact on the results.Available scoring and classification scores have significant limitations. CONCLUSIONS: Wet mount microscopy is a point-of-care, inexpensive, and fast technique that, with practice, can be mastered by office clinicians. It should be considered a basic skill in the curricula of gynecology and obstetrics residencies. Recommendations are provided on sampling, reading, and scoring.

Unwarranted hysterectomy in a case of oro-vaginal-vulvar lichen planus in a young woman: a case report.

BACKGROUND: Lichen planus is a rare autoimmune disease primarily affecting the skin and mucous membranes of the oral mucosa, vulva, and vagina. Diagnosis is difficult and often delayed as the clinicians do not associate the oral symptoms with the genital symptoms. This has a negative impact on the out-of-pocket expenditure and quality of life of the patients. We report this case, as only anecdotal cases have been reported so far from a developing country such as India. We highlight the unindicated hysterectomy that the patient had undergone because of lack of awareness regarding this condition. Our case report also highlights the importance of the multidisciplinary team approach to optimize outcomes and avoid unnecessary morbidity to such patients. CASE PRESENTATION: We report a North-Indian patient with oro-vaginal-vulvar lichen planus who presented to us with complaints of recurrent vulvovaginal symptoms for the last 5 years. She had been previously treated with multiple courses of antibiotics, antifungals, and topical steroids over the course of 3 years and finally offered laparoscopic-assisted vaginal hysterectomy (LAVH) by a private practitioner but got no relief. She also had complained of oral symptoms in the form of a burning sensation after eating spicy food, but did not seek any treatment for this. After multidisciplinary team discussion, a final diagnosis of oro-vaginal-vulvar lichen planus was made at our institute based on the clinical and histopathological findings. The patient was immediately started on oral prednisolone to which she responded with improvement in her symptoms. CONCLUSION: Lichen planus is a chronic painful condition with significant impact on the quality of life. Women often suffer for several years before an accurate diagnosis is made. Treatment is challenging and needs to be individualized with a multidisciplinary approach to prevent progressive anatomical distortion and associated morbidity.

Endometriosis presenting as vaginal polyps: outpatient vaginoscopic treatment.

OBJECTIVE: To demonstrate an outpatient vaginoscopic technique for treating multiple vaginal polyps. DESIGN: Demonstration of surgical technique using slides, pictures, and video. SETTING: Private hospital. PATIENT(S): Thirty-two-year-old nulligravid woman presenting to the gynecology clinic with one episode of intermenstrual bleeding, regular menstrual cycles with normal flow, and no history of dysmenorrhoea or dyspareunia. The genital local examination was normal, and speculum examination showed multiple vaginal lesions like polyps in the proximal posterior two-thirds and right lateral vaginal walls. Her transvaginal ultrasound read a normal uterus with a right ovarian simple cyst. INTERVENTION(S): The surgeon performed an outpatient operative vaginoscopy using a 5-mm continuous flow office hysteroscope with a 2.9-mm rod lens optical system and a 5F working channel. Distension of the vagina was achieved with a normal saline solution, and an intrauterine pressure of 50 to 60 mm Hg was maintained by an irrigation and aspiration electronic pump. An inspection of the vaginal walls, fornices, and the external cervical os (Fig. 1) revealed 10 vaginal lesions like polyps in the proximal two-thirds of the posterior and right lateral vaginal wall. The vaginal lesions (Fig. 2) varied in size from 0.5 cm to 4 cm. An excisional biopsy was performed and the sample sent for histopathologic evaluation. The vaginal lesions <2 cm in length were excised by cutting the base with scissors or using a bipolar vaporization electrode, which was connected to an electrocautery unit by a bipolar high-frequency cord. Vaginal lesions >2 cm were excised with the TruClear 5C Hysteroscopic Tissue Removal System (HTRS) with a zero-degree scope using the 2.9-mm incisor with a 5-mm cutting window at one end attached to a reusable handpiece with two connectors-one to the motor unit and second to the suction bottle with a collection bag. The overall diameter of TruClear 5C is 5.7 mm, and the optic size is 0.8 mm. The same irrigation pump is compatible with HTRS, and the pressure was increased to 150 mm Hg to maintain vaginal distension. Three factors influenced our decision to use the HTRS intraoperatively: the number and size of the vaginal lesions and the surgical time in the outpatient setting. A mechanical system that works on the principle of excising and aspirating tissue, the HTRS incisor has a rotatory action with the excising window placed against the most distal part of the vaginal lesions. The cutting action is controlled via a foot pedal attached to a motor control with 800 rotations per minute. The handpiece remains stationary while the polyp is excised and aspirated through the window into the collection bag. Minimal bleeding occurred and stopped spontaneously. The institutional ethics committee exempted this case report from review, and we obtained informed written consent from the patient. MAIN OUTCOME MEASURE(S): All vaginal lesions excised in an outpatient setting via vaginoscopy technique without anesthesia. RESULT(S): The operative time with the Bettocchi hysteroscope was 14 minutes, and HTRS was 6 minutes. The patient did not complain of pain but did describe minimal discomfort, rated on the visual analog scale as 2 (where ≥5 is severe pain). She was discharged 1 hour later. The histopathology was reported as vaginal endometriosis (ectopic presentation of endometriosis is rare, accounting for 0.02% of cases). After surgery, she was started on cyclical oral contraceptive pills (OCP) in the combination of 30 mg of ethinyl estradiol + 2 mg of dienogest because she desired to delay pregnancy by 1 year. She remained asymptomatic for 6 months. These contraceptive hormones are available in the form of oral pills, vaginal rings, and transdermal patches, and a physician can provide OCP continuously or cyclically. Continuous OCP is more efficacious for control of dysmenorrhoea, but cyclical OCP is preferred because it is affordable, tolerable, effective, produces no unpredictable bleeding, and slows the progression of the disease. (A cohort study found the contraceptive vaginal ring to be more effective for symptom-control in rectovaginal endometriosis with higher patient satisfaction than the transdermal patch; vaginal rings or transdermal patches are not available in some countries.) CONCLUSION(S): Vaginoscopy allows a more in-depth visualization of the vagina with complete inspection and removal of all polyps. Vaginoscopy is feasible in the outpatient setting and allows a comfortable, ergonomic position for the surgeon. Vaginoscopy or no-touch technique avoids the use of a speculum or tenaculum and results in minimal pain during the outpatient procedure.

Vulvovaginal atrophy of menopause and its impact on sexual function in an Italian clinical cohort of post-menopausal women.

The aim of current study was to estimate the impact of vulvovaginal atrophy (VVA) on sexual function in a clinical population of Italian postmenopausal women. Women aged 45-75 years with at least one VVA symptom completed three questionnaires: Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI) and Female Sexual Distress Scale revised (FSDS-R). A gynaecological examination was performed for VVA confirmation. Among the 1,066 evaluable patients, VVA was confirmed in around 90% of the sample. Sexual function impairment was significantly higher in patients with confirmed VVA as observed by significant differences in the sexual function component of the DIVA questionnaire (p = .014), the FSDS-R (p < .0005), and the FSFI (p < .0005), as well as for all the FSFI subdomains: desire (p < .0005), arousal (p < .0005), lubrication (p < .0005), orgasm (p < .0005), satisfaction (p < .0005) and pain (p < .0005). Significant impairment of sexual function was demonstrated in Italian postmenopausal women who were clinically confirmed with signs of VVA through gynaecological examination.IMPACT STATEMENTWhat is already known on this subject: At least half of postmenopausal women report VVA associated symptoms with significant impact on sexual function and ultimately on sexual activity.What the results of this study add: As compared with patients without confirmed VVA, the negative impact on sexual function was significantly higher in patients with confirmed VVA. This difference was observed for the sexual function component (DIVA-C) of the DIVA questionnaire, for the overall FSDS-R result, and for the overall FSFI score, as well as for all the FSFI subdomains (desire, arousal, lubrication, orgasm, satisfaction and pain).What the implications are of these findings for clinical practice and/or further research: An impairment of sexual function is significantly associated with VVA diagnosis in Italian post-menopausal women, especially when diagnosis was objectively confirmed by clinical signs of VVA visible in the gynaecological examination. In addition, this study demonstrates that inquiring about VVA using a structured questionnaire may increase the diagnosis of VVA related changes in sexual function.

Vaginal tuberculosis as differential diagnosis of cancer: A case report.

Tuberculosis remains a worrying public health problem. But if pulmonary tuberculosis's symptomatology is well known by the medical profession, this is not the case of genital tuberculosis. We take advantage of a case of vaginal tuberculosis to review the international literature about clinical diagnosis, further tests, and treatment of this extremely rare tuberculosis localization.