Oral contraceptive use and risk of vulvodynia: a population-based longitudinal study.

OBJECTIVE: To assess whether the risk of vulvodynia is associated with previous use of oral contraceptives (OCs). DESIGN: Longitudinal population-based study. SETTING: Four counties in south-east Michigan, USA. POPULATION: A population-based sample of women, aged 18 years and older, enrolled using random-digit dialling. METHODS: Enrolled women completed surveys that included information on demographic characteristics, health status, current symptoms, past and present OC use, and a validated screen for vulvodynia. The temporal relationship between OC use and subsequent symptoms of vulvodynia was assessed using Cox regression, with OC exposure modelled as a time-varying covariate. MAIN OUTCOME MEASURE: Vulvodynia, as determined by validated screen. RESULTS: Women aged <50 years who provided data on OC use, completed all questions required for the vulvodynia screen, and had first sexual intercourse prior to the onset of vulvodynia symptoms were eligible (n = 906). Of these, 71.2% (n = 645) had used OCs. The vulvodynia screen was positive in 8.2% (n = 74) for current vulvodynia and in 20.8% (n = 188) for past vulvodynia. Although crude cross-tabulation suggested that women with current or past vulvodynia were less likely to have been exposed to OCs prior to the onset of pain (60.7%), compared with those without this disorder (69.3%), the Cox regression analysis identified no association between vulvodynia and previous OC use (HR 1.08, 95% CI 0.81-1.43, P = 0.60). This null finding persisted after controlling for ethnicity, marital status, educational level, duration of use, and age at first OC use. CONCLUSION: For women aged <50 years of age, OC use did not increase the risk of subsequent vulvodynia.

Vulvar intraepithelial neoplasia: age, morphological phenotype, papillomavirus DNA, and coexisting invasive carcinoma.

Recent studies suggest that subsets of vulvar intraepithelial neoplasia (VIN) may be distinguished based on morphological presentation, the presence or absence of human papillomavirus (HPV) nucleic acids, and patient age. We analyzed 65 VIN lesions, including 15 with associated squamous cell carcinoma, to determine the relationship between pathological parameters associated with common types of VIN (multinucleation, koilocytosis, verruco-papillary morphology, diffuse atypia), rarer variants (differentiation, basal atypia), patient age, and papillomavirus nucleic acids. For all lesions higher mean ages were observed in patients with lesions that were associated with cancer and with well differentiated VIN variants with basal atypia only. A strong negative correlation with HPV nucleic acids was observed for differentiated variants with basal atypia (P = .002). In the common or "classic" VIN group patients with lesions with koilocytotic atypia, multinucleation, and verruco-papillary morphology were generally younger. However, no parameter or group of parameters defined a subset of patients with a significantly lower mean age or lesions with a higher index of HPV nucleic acids. Three of six lesions of lichen sclerosus (LS)-associated VIN, including one involving invasive carcinoma in elderly women, contained HPV nucleic acids; all three lesions exhibited the features of classic VIN. The finding of HPV across a broad age range suggests that this virus may play a role in vulvar neoplasia at any point in life. The direct demonstration of HPV nucleic acids within three LS-associated VINs is intriguing because it links two distinct risk factors to the same neoplasm.

Vaginal laceration following a jet-ski accident.

A 17-year-old woman riding as a passenger on a jet-ski fell behind the jet nozzle while jumping waves. A vaginal laceration with intra-abdominal extension occurred as a result of the accident. Hypogastric artery ligation controlled the hemorrhage and avoided more extensive surgery. The case represents an unusual injury from this type of watercraft and illustrates important points in the management of genital tract trauma.

Comparison of the ultrasonic scalpel to CO2 laser and electrosurgery in terms of tissue injury and adhesion formation in a rabbit model.

OBJECTIVE: To determine the relative effect of an ultrasonic scalpel on reproductive tissue compared with CO2 laser and electrosurgery. DESIGN: Prospective, randomized animal study. SETTING: University laboratory setting. ANIMALS: Sixteen New Zealand White rabbits. INTERVENTION(S): A steel scalpel, an ultrasonic scalpel, a CO2 laser, or electrosurgery were used to perform an ovarian wedge resection and to remove the distal uterine horn. A 3-cm longitudinal incision also was made in the uterine horn. MAIN OUTCOME MEASURE(S): The number of 1-second bursts of needle-tip electrosurgery required for hemostasis, the depth and degree of coagulation necrosis, degree of fibrin deposition, and postoperative adhesion formation. RESULT(S): The amount of electrosurgery needed to achieve hemostasis was less for any of the four power techniques than for the steel scalpel, with the exception of the ultrasonic scalpel at level 5 when used on the ovary. The depth (range: 0.30 to 0.38 mm) and the degree of coagulation necrosis was not different for any of the power techniques. The fibrin score was greatest for the ultrasonic scalpel at level 5 in both the ovarian tissue and the uterine tissue. There was no difference in adhesion scores for the power techniques and the steel scalpel. CONCLUSION(S): The ultrasonic scalpel at level 3 is not different from either CO2 laser or electrosurgery in terms of hemostatic properties, coagulation necrosis, or adhesion formation in the rabbit model.

Literature-filing system for vulvar conditions.

OBJECTIVE: To develop a classification system for the retrieval of stored material on various vulvar conditions. STUDY DESIGN: The major subject areas of vulvar conditions and management were identified. They were further classified into categories and subcategories. A numbering system was chosen for coding. The information was formatted to allow retrieval from the Internet in a framework ready for label printing. RESULTS: The classification system developed provides guidelines that are useful in making retrieval of stored material on various vulvar conditions more efficient. It can be expanded and personalized to fit the practitioner's needs and can be obtained from the Internet in the following manner by opening Netscape and entering the location: http:/(/)www.med.umich.edu/obgyn/vulva/ vulvalit.html. The filing system was formatted to allow standard, 5266, file-folder-sized label sheets to be inserted into the printer, allowing access to pretyped labels. A total of 464 labels will be printed. CONCLUSION: This system for retrieving vulvar information will be useful to many people, including clinicians, educators and researchers. The information is easily obtained from the Internet and printed in label form. It aids in the development of a system for life-long learning.

Vulvar conditions and their treatment. Evaluation of a patient information booklet.

OBJECTIVE: To identify the effectiveness of a patient information booklet on vulvar conditions and to evaluate future patient needs. STUDY DESIGN: A patient education booklet and satisfaction survey were distributed to 75 new patients with various vulvar conditions who were seen at the University of Michigan Center for Vulvar Diseases in 1996. This population's desire for health and disease information was analyzed. The 48-page booklet contains information on specific vulvar conditions most often seen, their common manifestations and treatment options. A survey with an attached, stamped envelope addressed for return to the Center for Vulvar Diseases was given to the patient along with the booklet during her initial visit to the clinic. Factors evaluated included the usefulness of the material, ease of reading, need for additional information and enhancement of communication with health care providers. RESULTS: Fifty-six percent of the surveys were returned. The majority of the patients found the material to be very useful and easy to read and understand. The booklet allowed better communication between patients and their health care providers. All the patients surveyed would recommend the booklet to a friend. Several of the patients utilize and desire computerized patient education. CONCLUSION: There is great consumer interest in patient education. A comprehensive booklet such as ours provides consistent information. Evaluation of patient education can provide important quality-improvement information to optimize health care services. Future patient needs are important factors to consider. The information in the booklet is available to the public on the internet at http:/(/)www.med.umich.edu/obgyn/vulva/ vulvedu.html.

Morphologic assessment of endometrium overlying submucosal leiomyomas.

The effect of submucosal leiomyomas on endometrial structure in women with symptomatic clinical findings was studied retrospectively. The endometrial histology from 13 hysterectomies for uterine leiomyomas was examined using three 2-mm sections of endometrium (one overlying a submucosal leiomyoma and two without underlying leiomyomas). Endometrial thickness, gland number and appearance, vessel number and diameter, and stromal inflammation were assessed. The thickness of the myometrium between the leiomyoma and the overlying 2-mm section of endometrium analyzed was also evaluated. The control group consisted of seven nonmyomatous uteri removed for benign disease. Analysis of the endometrium with underlying submucosal leiomyomas identified two groups using endometrial gland number as the criterion for this division. Five cases (group A) were found to have no endometrial glands, while the remaining eight (group B) had an average gland number of 74.5 per 2-mm section of endometrium. The mean gland number for the control group was 82.6, showing no significant difference from group B. Group A had an average endometrial area (2-mm thickness) of 0.38 mm2, and group B had an average area of 4.47 mm2, for a significant difference (t = -3.76, P = .007). Comparison of the two groups with the control group (mean area, 4.71 mm2) showed a significant difference in endometrial area only with group A (t = -7.64, P < .0005). A significant difference (t = -2.93, P = .019) was observed in the analysis of the thickness of the myometrium between the leiomyoma and overlying endometrium between groups A (mean thickness, 0.53 mm) and B (mean thickness, 1.70 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Psychosocial and sexual functioning in women with vulvodynia and chronic pelvic pain. A comparative evaluation.

OBJECTIVE: To determine whether women with vulvodynia differ from women with chronic pelvic pain and normal controls in their psychological functioning, somatic preoccupation, pain experience and sexual functioning. STUDY DESIGN: Cross-sectional, self-report study of women presenting to University of Michigan specialty and general clinics for the treatment of vulvodynia or chronic pelvic pain or seeking a routine gynecologic examination. All subjects completed questionnaires assessing demographic characteristics, pain, depressive symptoms, general affective state, marital adjustment, functional activity, somatic complaints, exposures, and medical and sexual history. Univariate analyses, chi 2 tests, analyses of variance and logistic regression were used to assess associations between these variables and the diagnostic category. RESULTS: Women with vulvodynia (n = 31) were similar to asymptomatic control women (n = 23) in demographic characteristics, sexual relationship variables, sexual behaviors, current and past depression, somatic sensitivity, and history of sexual or physical abuse. Women with chronic pelvic pain (n = 18) were younger and less educated than the other two groups and were more likely to have a history of physical and sexual abuse, to report recent depression and to screen positive for current depression, to have more work absences and to have more somatic complaints. CONCLUSION: Women with vulvodynia are psychologically similar to control women but differ significantly from women with chronic pelvic pain. A primary psychological cause of vulvodynia is not supported.

Use of the McGill Pain Questionnaire to compare women with vulvar pain, pelvic pain and headaches.

OBJECTIVE: To assess differences between women with three distinct types of chronic pain conditions using a modified McGill Pain Questionnaire. STUDY DESIGN: Data by self-administered questionnaire were collected on patients presenting to the University of Michigan Medical Center with chronic vulvar pain (144 patients), pelvic pain (198 patients) or headaches (130 patients). Data for analysis included: patient demographics, duration of pain and modified McGill Pain Questionnaire scores. Univariate and multivariate analyses were performed. RESULTS: Patients with vulvar pain had more formal education (P < .001), were more likely to be married (P < .001) and were less likely to be African American (P = .003) as compared to those with chronic pelvic pain and headaches. Chronic pelvic pain patients were younger than those in the other two groups (P = .002), and headache patients were likely to have had their chronic pain for a shorter duration than those with vulvar or pelvic pain (P < .001). Patients with vulvar pain had lower total scores on the McGill Pain Questionnaire as well as on the four subsets of variables: affective, sensory, cognitive and miscellaneous indexes (P < .001). They also chose fewer words to describe their symptoms from the 20-word lists (P < .001) and had lower average scores in each of the 20 categories as compared to the other two groups (P < .0001). Controlling for age, ethnicity and marital status did not alter this significance. CONCLUSION: Patients with vulvar pain were a unique groups when compared to other chronic pain populations. Evaluation of the demographics and McGill Pain Questionnaire scores confirmed the distinct qualities of women with vulvar pain.

Microglandular endocervical hyperplasia and tubal metaplasia: pitfalls in the diagnosis of adenocarcinoma on cervical smears.

The detection of atypical glandular cells of undetermined significance (AGUS) has risen recently due to the use of new endocervical canal sampling devices, in particular the cytobrush. From April 1993-June 1994, a diagnosis of AGUS ranging from adenocarcinoma in situ (AIS) to invasive adenocarcinoma was initially made on cervical smears from 6 women for whom histologic follow-up data were available. The purpose of this study was to determine if benign cervical glandular lesions can be reliably distinguished from adenocarcinoma on cytology. Review of the smears and histologic slides from 3 patients showed microglandular endocervical hyperplasia on cervical cone specimens. Cervical smears from 2 of these patients showed clusters of small-to-medium-sized cells with nuclei containing coarse, granular chromatin and prominent nucleoli. Cytoplasmic vacuoles and engulfment of neutrophils were present, findings suggestive of endometrial adenocarcinoma. The third patient's smear showed clusters of large cells with ample, vacuolated cytoplasm and vesicular nuclei containing prominent nucleoli, findings suggestive of endocervical adenocarcinoma. In 3 cases evaluated by cervical conization, histologic slides showed tubal metaplasia. The cervical smears showed clusters and sheets of cells with round-to-oval-shaped nuclei containing evenly distributed, finely granular chromatin and inconspicuous nucleoli. Pseudoglandular formation was present in 2 cases, a finding suggestive of AIS. Since the cytologic features of microglandular endocervical hyperplasia and tubal metaplasia overlap those of adenocarcinoma, a differential diagnosis is prudent on cytologic smears of AGUS.

Reporting of atypical squamous cells of undetermined significance on cervical smears: is it significant?

A retrospective 7-mo study (June 1, 1993-December 31, 1993) was performed to evaluate the significance of reporting atypical squamous cells of undetermined significance (ASCUS) on cervical smears. During this period 114 (0.7%) of 17,330 smears were diagnosed as ASCUS, 62 of which resulted in either follow-up cervical biopsies and/or endocervical curettages (61%) or repeat smears (39%), and form the basis of this study. Tissue specimens (38 cases) were negative in 24 cases (63%) and were positive in 14 cases (37%). Of the positive specimens, there were 9 low grade squamous intraepithelial lesions (LSIL) and 5 high grade squamous intraepithelial lesions (HSIL). Repeat smears (24 cases) were negative in 19 cases (79%) and were persistent for a lesion in 5 cases (21%). The persistent lesions consisted of 2 ASCUS and 3 LSIL. Overall, of the 62 cases, 43 (69%) were negative and 19 (31%) showed a lesion on follow-up tissue specimens or smears. Of the 62 cases, ASCUS diagnoses included cellular changes suggestive of human papillomavirus infection in 17 (27%) cases, nondiagnostic cellular changes in 16 (26%) cases, atypical squamous metaplasia vs. a squamous intraepithelial lesion (SIL) in 15 (24%) cases, inflammatory cell changes vs. a LSIL in 5 (8%) cases, 2 of which contained candida, and atrophic cellular changes in 1 (2%) case. In the remaining 8 (13%) cases, proper cytologic analysis was hampered by partially obscuring acute inflammation (3 cases) and low cellularity (5 cases). The results of this study would indicate that the reporting of ASCUS on cervical smears does lead to the detection of SILs in a significant number of cases (31% in this study). Therefore, further evaluation of the patient is suggested.

Neovaginal cytology after total pelvic exenteration for gynecological malignancies.

Vaginal reconstruction has become an established method to restore sexual function in women who have undergone ultraradical surgery and/or irradiation for the treatment of gynecologic malignancies. Cytologic evaluation of the neovagina serves a major role in the detection of recurrent disease. The purpose of this retrospective 6-yr study (January 1987-December 1993) was to evaluate the cytologic features of vaginal smear specimens from neovaginas constructed utilizing split-thickness skin grafts. Thirty-four vaginal smears were obtained at regular intervals from nine women (mean age: 51 yr) who underwent total pelvic exenteration with vaginal reconstruction for recurrent malignancies of the vagina and the cervix. Anucleated, keratinizing squames were a constant finding in each smear. Over a 4-mo-6-yr postoperative period, superficial and intermediate squamous cells were present in the majority of the smears and the maturation index showed a shift to the right. In two cases, a squamous cell carcinoma of the cervix recurred within the neovagina. Knowledge of the cytologic features associated with neovaginas is important in order to distinguish normal changes from neoplastic lesions.

Comparison of microscopic examination and human papillomavirus DNA subtyping in vulvar lesions of premenarchal girls.

STUDY OBJECTIVE: The purpose of this study is to compare the microscopic examination and human papillomavirus (HPV) DNA subtyping of vulvar specimens from premenarchal girls clinically diagnosed with condyloma to determine whether DNA subtyping aids in the diagnostic process. DESIGN: A retrospective chart review was performed on all premenarchal girls who underwent surgical treatment of clinically diagnosed condyloma between 1993 and 1999 at the University of Michigan Medical Center by the Pediatric and Adolescent Gynecology Service. Tissue was sent for pathologic evaluation and in 10 patients the specimens also underwent DNA subtyping. One patient had prior DNA subtyping. All the other lesions were surgically ablated. The microscopic slides were reviewed by a single pathologist blinded to the study. SETTING: The study was performed in a tertiary care university hospital. PARTICIPANTS: The study group included 11 premenarchal girls with an average age of 2.3 yr. MAIN OUTCOME MEASURES: The charts were reviewed for previous HPV treatment, maternal history of HPV, history of sexual abuse, microscopic diagnosis, and HPV DNA subtyping. RESULTS: Four patients had prior surgical treatment and two patients had undergone prior medical treatment. The microscopic diagnosis was condyloma in 8 patients, chronic dermatitis in 2 patients, and 1 patient had VIN 2-3. All 11 specimens tested positive for HPV DNA, 10 specimens contained at least one of the low-risk subtypes (6, 11, 42, 43, 44), and 1 tested positive for low-risk as well as intermediate/high-risk HPV subtypes (16, 18, 31, 33, 35, 45, 51, 52, 56). CONCLUSIONS: Although all the patients with a clinical diagnosis of condyloma tested positive for HPV DNA, only 9 of 11 were definitely diagnosed with HPV-related pathology by microscopic examination. Therefore, in premenarchal patients with verrucous lesions in the anogenital area, microscopic evaluation alone may be inadequate as a confirmatory test when a positive clinical diagnosis has been made, and HPV DNA subtyping should be considered to avoid confusion with the diagnosis.

Current evaluation and management of vulvovaginitis.

There are many problems in the diagnosis and treatment of vaginitis. Often, the patient is not examined (telephone treatment) or examined improperly with lack of attention to the wet prep. In patients with recurrent vaginitis, it should not be assumed that the current infection is the same as a previous infection without a thorough examination. At times, there is an overuse of topical steroids for all vulvar symptoms or use of antifungals for all vulvar symptoms. The various abnormalities in vulvovaginitis have unique physical findings, laboratory tests, and treatments. It should be remembered that unusual conditions of the vagina and vulva may resemble vulvovaginitis. Many vulvar conditions must be considered when a patient reports discharge and itching. It is important to remember that if the treatment is not working, reconsider the diagnosis.

Contraceptive management for female adolescents with mental retardation and handicapping disabilities.

Adolescent girls with mental retardation and handicapping disabilities have a need for sexual counseling and contraceptive management. Societal attitudes have changed, allowing these patients to experience normal and satisfying sexuality. The reproductive health concerns of these patients are extensive. Contraceptive selection varies with regard to the mental and physical capabilities of individual patients. The use of barrier methods, intrauterine devices, oral contraceptives, intramuscular medroxyprogesterone acetate, and sterilization has been discussed thoroughly in the past. No formal studies have been performed to evaluate the use of subdermal levonorgestrel implants in patients with mental retardation and physical disabilities.

PIP: Society has become more accepting of sexual relations by and among the mentally and physically disabled. Accordingly, these individuals are increasingly able to enjoy more normal and satisfying sexual experiences, and have grown to need counseling on sexual activity, sexual abuse, temporary contraception, and sterilization. Contraceptive selection varies with regard to the mental and physical capabilities of individual patients. While the literature has studied the applicability of barrier methods, IUDs, oral contraceptives, intramuscular medroxyprogesterone acetate, and sterilization as contraceptive methods, formal studies have yet to be conducted on the use of subdermal levonorgestrel implants in these individuals. This paper discusses reproductive health concerns, care facilities, and contraceptive management with regard to sex education and contraceptive selection.

Home study course: spring 2001.

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Cytopathological findings on vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease.

BACKGROUND: Periodic, routine Papanicolaou smears of cells from the vagina are commonly examined in women who have undergone a hysterectomy for benign gynecologic disease. The benefits of this method of screening are not known. METHODS: We analyzed Papanicolaou smears obtained from the vaginal apex (cuff) in 6265 women at Charity Hospital in New Orleans between January 1, 1992, and December 31, 1994. Of the 10,595 vaginal smears, an estimated 9610 were obtained during follow-up examinations of 5682 women who had undergone hysterectomy for benign gynecologic disease. RESULTS: Among these 9610 vaginal smears, 104, from 79 women, were abnormal. The abnormal smears were categorized according to the findings, as follows: atypical squamous cells of undetermined significance, 52 (0.5 percent of all smears); low-grade squamous intraepithelial lesion, 44 (0.5 percent); high-grade squamous intraepithelial lesion, 6 (0.1 percent); and squamous-cell carcinoma, 2 (0.02 percent). In five women, biopsies revealed vaginal intraepithelial neoplasia type I or II; there were no biopsy-proved cases of vaginal cancer. The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent (95 percent confidence interval, 0 to 33 percent). CONCLUSIONS: The prevalence of abnormal findings on cytopathological examination of vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease is extremely low.

Lichen sclerosus in pregnancy: presentation of two cases.

Numerous skin diseases occurring in the pregnant patient have been reported. Some of these diseases are unique to pregnancy and some, including vulvar varicosities, vulvar edema, postpartum labial adhesions, and hematomas, are a result of physiological changes of pregnancy or the birth process. In addition, a variety of viral and bacterial infectious diseases of the vulva may occur during pregnancy. Vulvar neoplasms may also be found in pregnancy. In two patients, ages 27 and 31, lichen sclerosus first was diagnosed during their initial prenatal visits. Only one of the patients was symptomatic. The symptomatic patient used topical steroids for relief of vulvar itching. Two patients with lichen sclerosus of the vulva in pregnancy are reported, with emphasis on the diagnosis and treatment of this condition.