Vaginal pH: a simple assessment highly correlated with vaginal morphology and symptoms in postmenopausal women.

OBJECTIVE: The aim of the study was to determine the utility of vaginal pH as a marker of menopause and vulvar and vaginal atrophy (VVA) before and after local estrogen treatment. METHODS: Vaginal pH was determined using standard pH paper strips in two clinical trials involving postmenopausal women with signs and symptoms of VVA evaluated before and after intervention with vaginal estradiol in softgel capsules. The utility of vaginal pH was evaluated as a screening method for VVA due to menopause and correlations were analyzed between vaginal pH and VVA symptoms, physical changes, and maturation of the vaginal epithelium. RESULTS: Changes in vaginal pH were significantly correlated with changes in superficial and parabasal cell counts; vaginal epithelial changes of color, integrity, thickness, and secretion; and the VVA symptoms of vaginal dryness and dyspareunia (vaginal pain with intercourse). CONCLUSIONS: Vaginal pH consistently correlated with parabasal and superficial cells and the visual vaginal epithelial changes and symptoms of dryness and dyspareunia, and is thus a simple outpatient procedure that reflects the hormonal milieu and its effects on the vaginal epithelium.

Assessment of vaginal atrophy: a review.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to provide an evidence-based definition of vaginal atrophy (VA) and present an overview of subjective and objective measurements of VA applicable in clinical practice and research. METHODS: A systematic literature search was performed in MEDLINE and EMBASE to identify studies reporting on measurement properties of diagnostic instruments for VA. Additional searches in MEDLINE aimed to document the definitions, diagnostic criteria, and outcome measures of VA. Studies reporting on definitions, diagnosis, outcome measurements, and measurement properties of diagnostic instruments of VA were selected. RESULTS: Specific symptoms for VA that were consistently described could be identified to suggest an evidence-based definition of VA. As subjective outcome measurements, seven scoring systems to assess the signs of VA during physical examination were identified. The most bothersome symptom (MBS) approach is most useful in clinical practice and research as it focuses on the most common symptoms of VA. As objective outcome measurements, numerous ways to assess vaginal cytology and vaginal pH were identified. CONCLUSIONS: At the moment, there is no consensus on the definition and assessment of VA. We propose to define VA as a common manifestation of estrogen decline associated with specific symptoms of which the most common are: vaginal dryness, itching or irritation, and dyspareunia. In both clinical and research settings, subjective assessment (the MBS approach) and objective assessments of VA (measurement of vaginal maturation index and vaginal pH) should be combined.

Vaginal Dryness and Beyond: The Sexual Health Needs of Women Diagnosed With Metastatic Breast Cancer.

While research on the sexual health of women with early stage cancer has grown extensively over the past decade, markedly less information is available to support the sexual health needs of women diagnosed with advanced breast cancer. Semistructured interviews were conducted with 32 women diagnosed with metastatic breast cancer (ages 35 to 77) about questions they had concerning their sexual health and intimate relationships. All participants were recruited from a comprehensive cancer center at a large Midwestern university. Three themes were examined: the role of sexual activity and intimate touch in participants' lives, unmet information needs about sexual health, and communication with medical providers about sexual concerns. Findings indicated that sexual activities with partners were important; however, participants worried about their own physical limitations and reported frequent physical (e.g., bone pains) and vaginal pain associated with intercourse. When women raised concerns about these issues in clinical settings, medical providers often focused exclusively on vaginal lubricants, which did not address the entirety of women's problems or concerns. In addition, women diagnosed with metastatic breast cancer reported needing additional resources about specialized vaginal lubricants, nonpenetrative and nongenitally focused sex, and sexual positions that did not compromise their physical health yet still provided pleasure.

Ospemifene: first global approval.

Ospemifene (Osphena™) is an oral selective estrogen receptor modulator (SERM), with tissue-specific estrogenic agonist/antagonist effects. QuatRx Pharmaceuticals conducted the global development of the agent before licensing it to Shionogi for regulatory filing and commercialization worldwide. Ospemifene is the first non-estrogen treatment approved for moderate to severe dyspareunia in women with menopause-related vulvar and vaginal atrophy. The drug is approved in the USA, and application for EU regulatory approval is underway. This article summarizes the milestones in the development of ospemifene leading to this first approval for moderate to severe dyspareunia, a symptom of postmenopausal vulvar and vaginal atrophy.

Correlation or confusion: the need for accurate terminology when comparing magnetic resonance imaging and clinical assessment of congenital vaginal anomalies.

OBJECTIVE: To examine the terminology used when describing clinical and magnetic resonance imaging (MRI) findings in the investigation of complex congenital Mullerian anomalies. PATIENTS AND METHODS: Forty-four girls and women with complex congenital Mullerian anomalies underwent vaginal examination and pelvic MRI. The findings from both procedures were compared. Different terms used to refer to the vagina were noted. Where clinical and MRI results were discordant, findings and terminology were reviewed by the multidisciplinary team. RESULTS: Eleven different terms were used to describe vaginal anatomy. In 10 cases (23%) clinical and MRI findings appeared discordant. On review, it became clear that in all but two cases identical findings were being described using different vocabulary. CONCLUSION: At present, there is no standard descriptive terminology recommended for these anomalies and clinical confusion can arise. A uniform protocol for terminology should be agreed between specialists undertaking this work.

Optical coherence tomography compared with colposcopy for assessment of vaginal epithelial damage: a randomized controlled trial.

OBJECTIVE: Colposcopy has been used to detect epithelial damage with vaginal microbicides. In animal models, optical coherence tomography provided increased sensitivity over colposcopy in detecting epithelial injury. This randomized, double-blinded, clinical study compared optical coherence tomography to colposcopy for the evaluation of epithelial injury in women using placebo or nonoxynol-9. METHODS: Thirty women aged 18-45 were randomized to use hydroxyethyl cellulose placebo or nonoxynol-9 vaginal gel twice daily for 5.5 days. Imaging with colposcopy and optical coherence tomography was performed before product use, after the last dose, and 1 week later. Colposcopy was graded using standard criteria. Optical coherence tomography images were scored for epithelial integrity based on a published scoring system and were measured for epithelial thickness. RESULTS: Colposcopy findings, optical coherence tomography scores, and epithelial thicknesses were similar between treatment groups at baseline. After treatment, there were significant differences between the nonoxynol-9 (1.37) and control group (1.15) optical coherence tomography scores (P<.001), indicating epithelial injury, and there was epithelial thinning in the nonoxynol-9 group (237 micrometers) compared with the control group (292 micrometers; P=.008). There were no significant posttreatment colposcopic differences in epithelial disruption between treatment groups, with only increased erythema noted after nonoxynol-9 use (P=.02). CONCLUSION: Optical coherence tomography detected epithelial disruption and thinning not identified by colposcopy. Vaginal epithelial thickness, a measure previously available only through biopsy, decreased after nonoxynol-9 use, a finding that may contribute to increased susceptibility to human immunodeficiency virus after frequent use. Optical coherence tomography shows promise for the noninvasive clinical assessment of vaginal epithelial damage. CLINICAL TRIAL REGISTRATION: UMIN Clinical Trials Registry, www.umin.ac.jp/ctr/index.htm, R000006186. LEVEL OF EVIDENCE: I.

Overlooked diseases of the vagina: a directed anatomic-pathologic approach for imaging assessment.

The vagina can easily be overlooked at ultrasonography (US), computed tomography (CT), or magnetic resonance (MR) imaging performed for nongynecologic indications. Even when gynecologic disease is suspected, the vagina may be underevaluated at routine pelvic US due to probe positioning and at CT due to poor vaginal tissue characterization. Although MR imaging offers excellent tissue characterization, radiologists must focus on the vaginal area to recognize any incidental findings. A directed anatomic-pathologic approach to assessing the vagina at US, CT, and MR imaging is recommended so that pertinent findings are not missed. This approach requires a knowledge of the anatomy and embryologic development of the vagina, as well as an understanding of congenital, developmental, and postoperative vaginal disease entities. In addition, it is important to understand the strengths and limitations of each imaging modality with respect to vaginal assessment. By remembering to "look beyond" the uterus and cervix to the vagina, radiologists can improve their perception and interpretation of vaginal anatomy and disease.

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis.

OBJECTIVE: To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE). METHODS: This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed. RESULTS: DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%). CONCLUSION: MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.

Home sampling and pooling of vaginal samples are effective tools for genetic screening of Chlamydia trachomatis among high school female students in Lithuania.

The aims were 1) to estimate the prevalence of C. trachomatis infection among sexually active female students in Kaunas, Lithuania; 2) to investigate the usefulness of personal invitation, self-sampling, and pooling of samples for screening; and 3) to evaluate the costs of the approaches used. A cross-sectional study inviting 795 female students (18-31 y of age) from 7 high schools and 1 college in Kaunas was performed. The response rate was 67% (533/795). Self-obtained vaginal samples were analysed, individually and pooled (n = 3), using Digene Hybrid Capture II CT/NG Test. The overall prevalence of C. trachomatis infection was 5.6%. Among the sexually active female students 20-24 y of age (n = 424), the prevalence was 7.1%; however, the prevalence varied from 0% to 14.2% at the different schools. For estimation of the population prevalence based solely on identification of C. trachomatis positive pools, the pooling strategy reduced the costs by 85%. For estimation of population prevalence and for diagnosis of each individual sample, pooling reduced the costs by 70%. Targeted screening, using pooling to reduce the expenses, mainly of 3rd and 4th y Lithuanian female students could be recommended. By extended personal contact and internet-based communication, increased participation rates may be attained.

[Assessment of painful sexual intercourse occurrence among women in gynaecological practice]. / Ocena wystepowania bolesnego wspólzycia u kobiet w praktyce ginekologicznej.

OBJECTIVES: Analysis of painful sexual intercourse occurrence among women who are patients of a gynaecological practice. MATERIAL AND METHODS: 104 women have been examined by means of self-constructed questionnaire consisting of parts A and B. All interviewees had had sexual intercourses. Part A of the questionnaire included questions concerning painful sexual intercourse and was completed by the interviewees, whereas part B included questions concerning the presence of symptoms of vulvar vestibulitis and was completed by the gynaecologist after the examination. Statistical analysis was performed by means of chi-quadrat test. RESULTS: Out of 104 examined women, 20 patients (19.2%) complained of painful intercourse occurrence. CONCLUSION: 1. Women at all ages experience painful intercourse, although there are different reasons for its occurrence. 2. Women may experience pain connected with sexual intercourse although they never experienced intercourse with vaginal penetration. 3. In case of 1/4 of women, coital pain occurs at the attempt of intercourse or "at the very thought of it". 4. Pain during sexual intercourse occurs in case of almost 50% of post menopausal women, experiencing vaginal dryness. 5. Since 30% women with visible features of vulvar vestibulitis, detected during gynaecological examination, experience painful sexual intercourse, gynaecological examination should constitute a constant element of diagnosis of painful sexual intercourse among women.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings.

PURPOSE: The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings. MATERIALS AND METHODS: We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty-two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul-de-sac obliteration). RESULTS: Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul-de-sac obliteration, which were more easily detected by MR. CONCLUSIONS: Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

MR imaging evaluation of the pelvic floor for the assessment of vaginal prolapse and urinary incontinence.

Pelvic MR imaging using the combination of motion-insensitive T2-weighted single-shot fast spin echo and high soft tissue resolution standard T2-weighted fast spin echo techniques has helped to identify soft tissue abnormalities that directly correlate with the clinical and intraoperative findings related to pelvic floor prolapse. In particular, the authors have shown that pelvic MR imaging has the ability to identify changes related to uterosacral ligament disruption and to document the corrective changes after surgical repair of this ligament. In the future, pelvic MR imaging is expected to play a progressively larger role in preoperative planning for complex or uncertain cases and for more detailed evaluation of repair in cases that do not show good symptomatic response. Pelvic MR imaging should also help to document and advance knowledge of surgical repair methodology.

Rectal endoscopic ultrasound with a radial probe in the assessment of rectovaginal endometriosis.

STUDY OBJECTIVE: To evaluate the accuracy of rectal endoscopic ultrasound and to evaluate endometriosis in the rectovaginal septum, rectum, and sigmoid walls. DESIGN: Validation of diagnostic test (Canadian Task Force classification II-1). SETTING: Tertiary care hospital. PATIENTS: Thirty-two consecutive women clinically suspected of having rectovaginal septum endometriosis without previous surgical treatment. INTERVENTION: Colonoscopy, transrectal ultrasound, and rectal endoscopic ultrasound, followed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: The disease was classified according to 1996 standards of the American Society of Reproductive Medicine. Images obtained by colonoscopy, endoscopic ultrasound, and surgery and histologic findings were compared. In 6 patients endometriosis infiltrated bowel muscularis wall, in 20 it infiltrated rectovaginal septum, and in the remaining 6 there was no evidence of lesions. In all women in whom infiltration of the intestinal wall was suspected, rectal endoscopic ultrasound and colonoscopy confirmed the lesions (sensitivity 100%, specificity 67%). CONCLUSION: Endoscopic ultrasound was useful in preoperative assessment of women with endometriosis.

Vaginal dryness assessment in postmenopausal women using pH test strip.

OBJECTIVE: To objectively analyze vaginal dryness in postmenopausal women. METHODS: Forty healthy postmenopausal women, were divided in three groups according to the treatment they received. Group I, conjugated equine estrogens (CEE) 0.625 mg/day (n=20), group II, CEE 0.625 mg/day plus chlormadinone 1 mg/day (n=13), and group III, CEE 0.625 mg/day plus medroxyprogesterone 2.5 mg/day (n=7). Vaginal dryness intensity was analyzed using an analog visual scale, and vaginal humidity measuring the moistening in mm of a pH test strip. Both were evaluated at baseline and 3 months after the beginning of treatment. The comparison among groups and between the baseline and final results was done with Student's t-test for paired and independent samples, respectively. Pearson correlation analysis was carried out between final vaginal dryness intensity and the final moistening of the pH test strip. RESULTS: No statistically significant differences were found in age neither in somatometric variables among the groups. In the three groups, vaginal dryness intensity significantly decreased and the pH test strip moistening significantly increased. A significant negative correlation was only found in group II (-0.690 P<0.009). CONCLUSIONS: Vaginal dryness evaluation assessing the pH test strip moistening is an objective method to evaluate this symptom in postmenopausal women, and the results are independent of the hormone replacement therapy schedule.

Aspectos biológicos, socioeconömicos e culturais de mulheres com corrimento vaginal / Biologycals socio-cultural-economics aspects women with vaginal discharge

Apesar do corrimento vaginal ser uma das mais antigas e frequentes afecçöes que acometem a saúde física e emocional da mulher, do diagnóstico laboratorial ser relativamente fácil e de baixo custo, das recidivas e reinfecçöes serem constantes, ainda na atualidade, sua abordagem é feita de maneira simplista e empírica, tanto para o diagóstico como para a terapêutica. Este estudo objetiva enfatizar a importåncia de uma abordagem holística no atendimento à mulher com corrimento vaginal, pois acreditamos que tal afecçäo, suas recidivas e reinfecçöes näo estäo exclusivamente associadas a infectividade e virulência do patógeno envolvido, mas também ao contexto socioeconömico e cultural em que a mulher está inserida

Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse.

OBJECTIVE: The objective of this study was to determine the accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. STUDY DESIGN: A retrospective chart review of all women undergoing surgery for anterior vaginal wall prolapse during the years of 1994 to 1996 identified operative notes that described the surgical assessment of paravaginal support. These surgical findings were compared with the preoperative clinical assessment. Clinical parameters that predicted poor correlation were identified. Statistical analysis used the chi(2) test. RESULTS: One hundred seventeen patients had surgery for anterior vaginal prolapse. Seventy had documentation of an intraoperative paravaginal support evaluation. Of these, 44 patients had vaginal procedures, and 26 had abdominal procedures. All patients had at least stage 2 prolapse before surgery, and all were noted to have excellent pelvic support 4 to 6 weeks after surgery. The prevalence of paravaginal defects at surgery was 47% on the right and 41% on the left. The sensitivity and negative predictive value for the clinical assessment for paravaginal defects were good on both the right and left sides, whereas the specificity and positive predictive values were poor. Stage of prolapse, previous hysterectomy, or previous anterior colporrhaphy did not significantly affect the accuracy of the clinical examination in predicting fascial defects. However, previous retropubic urethropexy did significantly decrease the accuracy of the clinical examination in predicting right paravaginal defects (P <.01) but not left. CONCLUSION: Although preoperative clinical assessment for paravaginal defects is useful, it does not substitute for careful intraoperative evaluation for endopelvic fascial defects.

Diagnosis and follow-up of Chlamydia trachomatis infections in the ED.

The purpose of this study was to determine the impact on patient care and the cost effectiveness of testing for chlamydial infection in the emergency department. All patients tested for chlamydial infection in three emergency departments between October 1, 1993 and January 31, 1994 were retrospectively reviewed for charges and adequacy of therapy. In one hospital, the effectiveness of a call-back system to enhance proper therapy of inadequately treated patients was evaluated. Of 2,416 test results, 249 were positive, and 197 of these charts were available for review. All 16 male patients were treated appropriately at the initial visit; 105 of 181 female patients were inadequately treated at the initial visit. The charge to identify each patient inadequately treated was $981.22 ($103,000 for 105). Of the 28 inadequately treated patients receiving a follow-up call, 20 sought treatment. The high cost of testing patients cannot be justified without an adequate surveillance system to enhance proper follow-up treatment.

Identifying cervical infection among pregnant women in Nairobi, Kenya: limitations of risk assessment and symptom-based approaches.

OBJECTIVES: To examine characteristics of pregnant women associated with cervical infection, and to evaluate the accuracy of symptom-based and risk assessment systems which have been developed for identifying cervical infection in antenatal women. METHODS: Interviews were conducted and physical examinations performed on 291 consecutive antenatal clinic attenders in nairobi, Kenya. Vaginal, cervical, urine and blood specimens were also obtained for analysis. RESULTS: The following disease prevalences were observed: candidiasis 26.2%; trichomoniasis 19.9%; bacterial vaginosis 20.6%; any vaginal infection 53.8%; chlamydial cervicitis (CT) 8.8%; gonococcal cervicitis (GC) 2.4%; any cervical infection 10.8%. The only statistically significant association with GC and/or CT cervical infection was the presence of cervical friability (OR = 2.1, P = 0.05). There were trends towards associations with the presence of endocervical mucopus (OR = 2.6, P = 0.06), reporting a new sex partner in the past 3 months (OR = 2.2, P = 0.16) and reporting that a sex partner had an STD-related symptom (OR = 4.4, P = 0.13). There were no associations with other demographic, behavioural or medical characteristics. Risk scores previously developed for detecting GC/CT cervicitis in developing country antenatal populations generally performed poorly. CONCLUSIONS: The prevalences of vaginal and cervical infection observed were extremely high among these "low risk" women. Owing probably to high levels of vaginal infection and to behavioural characteristics of this urban population, factors which elsewhere have been associated with cervical infection were not found to be so in this setting. Further work on symptom-based approaches and risk assessment for STD case detection in pregnant women is required before STD management recommendations can be generalised.