Laser Therapy for Recalcitrant Vulvar Lichen Sclerosus: A Review of the Literature.

Vulvar lichen sclerosus (LS) is a chronic vulvar dermatosis potentially impacting quality of life and sexual function. While most women with LS respond to topical corticosteroids and/or calcineurin inhibitors, some require additional therapy. Systemic therapies have been used successfully in oral and vulvovaginal lichen planus with minimal data in the setting of LS. Likewise, while vaginal laser therapy has shown potential benefit for genitourinary syndrome of menopause, there is a paucity of data in the setting of LS. We review retrospective and prospective studies along with randomized controlled trials utilizing vulvovaginal laser for LS therapy.

Retrospective 15-Year Review of Anal Cytology Screening in Women at Mayo Clinic Rochester, Minnesota.

OBJECTIVES: Anal cytology is a modality for anal cancer screening in high-risk women. In this retrospective study, we review risk factors associated with abnormal anal cytology and unsatisfactory anal cytology rates, and correlate findings of cytology with histological results. METHODS: A retrospective cohort study of anal cytology screening in women at Mayo Clinic in Rochester, Minnesota from 2002 to 2018 was conducted. RESULTS: Three hundred fifty-seven women had a total of 592 anal cytologies performed. Three hundred seventeen women had screening anal cytology, whereas 40 women had anal cytology for surveillance given a history of anal intraepithelial neoplasia (AIN) or anal cancer. An unsatisfactory anal cytology result was found in 14.7%. Risk factors, type of follow-up, and correlation with histologic specimens were also reviewed. Histologic finding of AIN 2/3 correlated with abnormal anal cytology 84% of the time in this cohort. CONCLUSIONS: High-risk women should be screened on a periodic basis for anal cancer. Anal cytology is one possible modality that can be used. Further insight into AIN progression, regression, recurrence, and outcome after treatment will help direct future screening recommendations.

Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting.

This multidisciplinary consensus update aligns prior Society of Radiologists in Ultrasound (SRU) guidelines on simple adnexal cysts with recent large studies showing exceptionally low risk of cancer associated with simple adnexal cysts. Most small simple cysts do not require follow-up. For larger simple cysts or less well-characterized cysts, follow-up or second opinion US help to ensure that solid elements are not missed and are also useful for assessing growth of benign tumors. In postmenopausal women, reporting of simple cysts greater than 1 cm should be done to document their presence in the medical record, but such findings are common and follow-up is recommended only for simple cysts greater than 3-5 cm, with the higher 5-cm threshold reserved for simple cysts with excellent imaging characterization and documentation. For simple cysts in premenopausal women, these thresholds are 3 cm for reporting and greater than 5-7 cm for follow-up imaging. If a cyst is at least 10%-15% smaller at any time, then further follow-up is unnecessary. Stable simple cysts at initial follow-up may benefit from a follow-up at 2 years due to measurement variability that could mask growth. Simple cysts that grow are likely cystadenomas. If a previously suspected simple cyst demonstrates papillary projections or solid areas at follow-up, then the cyst should be described by using standardized terminology. These updated SRU consensus recommendations apply to asymptomatic patients and to those whose symptoms are not clearly attributable to the cyst. These recommendations can reassure physicians and patients regarding the benign nature of simple adnexal cysts after a diagnostic-quality US examination that allows for confident diagnosis of a simple cyst. Patients will benefit from less costly follow-up, less anxiety related to these simple cysts, and less surgery for benign lesions.

Management of etonogestrel subdermal implant-related bleeding.

OBJECTIVE: To determine removal rates for unacceptable bleeding in etonogestrel subdermal implant (ESI) users treated with reassurance alone as well as in those receiving reassurance plus medical interventions including doxycycline and ibuprofen, and to compare removal rates between ESI users treated with reassurance alone with those receiving the medical interventions listed above in addition to reassurance. STUDY DESIGN: Medical records of 391 women receiving ESI for contraception within the period June 2007-April 2011 were abstracted for patient characteristics and interventions including reassurance, doxycycline, and ibuprofen. Removal rates were compared between intervention groups using the chi2 test and multivariable logistic regression. RESULTS: Contact for bleeding occurred in 128 women (32.7%). Of those, 83 women (21.2% of entire cohort) requested removalfor bleeding (median, 381 days; range, 29-1,078 days). Of 53 women receiving reassurance alone, 40 (75.5%) requested removal, whereas fewer (15 of 33 [45.5%]) women receiving reassurance plus doxycycline requested removal (p = 0.005), even after adjusting for prior contraception use and body mass index at ESI insertion (p = 0.006). Of 10 women receiving ibuprofen and 19 women receiving doxycycline plus ibuprofen, 7 (70.0%) and 11(57.9%), respectively, requested removal for bleeding. CONCLUSION: Reassurance plus doxycycline is associated with lower removal rates for ESI-related bleeding than is reassurance alone.

Comparison of dysplastic and benign endocervical polyps.

OBJECTIVE: This study aimed to estimate dysplasia rate in histologically evaluated endocervical polyps and to compare histological and clinical characteristics of dysplastic (D) polyps with those displaying representative benign changes. MATERIALS AND METHODS: Endocervical polyps removed at Mayo Clinic from January 1994 to December 2010 were categorized as polyp without other descriptors, benign polyp variants, adenomatous or reactive atypical (AR) polyps, and D polyps. Clinical characteristics, cervical cytological result, and polyp histological result of patients in the latter 2 categories were compared. RESULTS: Among the 4,328 patients with endocervical polyps, 3,656 were classified as polyp without other descriptors, 628 as benign polyp variants, 34 as AR polyps, and 9 as D polyps. Dysplasia was mild in 4 polyps, moderate in 1 polyp, and severe in 4 polyps. Overall risk of dysplasia was 0.2%. Patients with D polyps were younger (mean = 40.3 vs. 49.8 years, p = .009) and more likely to have abnormal cervical cytological result before polyp removal (67% vs. 21%, p = .014) as compared with those with AR. Patients with D polyps tended to have a polyp greater than 20 mm (44% vs. 15%, p = .074) compared with those with AR polyps. Associated endometrial pathological diagnosis was limited to a prolapsed endometrial polyp in 1 patient and submucosal endometriosis in 1 patient. CONCLUSIONS: Patients with D polyps were younger and had a greater likelihood of abnormal cytological result before polyp removal. No polyp size threshold below which dysplasia could be excluded was identified. No primary cervical cancer, endometrial hyperplasia, or cancer was identified.

Patient understanding of the revised USPSTF screening mammogram guidelines: need for development of patient decision aids.

BACKGROUND: The purpose of the study was to examine patients' understanding of the revised screening mammogram guidelines released by the United States Preventive Services Task Force (USPSTF) in 2009 addressing age at initiation and frequency of screening mammography. METHODS: Patients from the Departments of Family Medicine, Internal Medicine, and Obstetrics and Gynecology (n = 150) at a tertiary care medical center in the United States completed a survey regarding their understanding of the revised USPSTF guidelines following their release, within four to six months of their scheduled mammogram (March 2010 to May 2010). RESULTS: Of the patients surveyed, 97/147 (67%) indicated increased confusion regarding the age and frequency of screening mammography, 61/148 (41%) reported increased anxiety about mammograms, and 58/146 (40%) reported anxiety about their own health status following the release of the revised screening guidelines. Most of the patients surveyed, 111/148 (75%), did not expect to change their timing or frequency of screening mammograms in the future. CONCLUSION: Results from this survey suggested increased confusion and possibly an increase in patients' anxiety related to screening mammography and their own health status following the release of the revised USPSTF screening mammogram guidelines to the public and subsequent media portrayal of the revised guidelines. Although the study did not specifically address causality for these findings, the results highlight the need for improvements in the communication of guidelines to patients and the public. Development of shared decision-making tools and outcomes should be considered to address the communication challenge.

Evaluation and Management of Vaginitis.

Vaginitis is a common concern for women across the lifespan. Vaginal symptoms may impact quality of life, and clinicians are challenged in the evaluation and management of bacterial vaginosis, Candida vaginitis, trichomoniasis, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause.

Contraceptive Challenges in Women With Common Medical Conditions.

Women have the opportunity to meet personal contraceptive goals with convenient, highly reliable, and easily reversible methods. Long-acting reversible contraception represents an increasingly popular option for most women throughout the reproductive lifespan. Nonetheless, many women and their health care providers are challenged by coexisting medical issues. We aim to help clinicians individualize contraception and use shared decision-making to enhance patient satisfaction and continuation with their method.

Evaluation and Management of Abnormal Uterine Bleeding.

Abnormal uterine bleeding (AUB) is a common condition that leads to increased health care costs and decreased quality of life. A systematic approach to AUB evaluation can simplify management and enhance women's well-being. Abnormal uterine bleeding describes any variation from normal bleeding patterns in nonpregnant, reproductive-aged women beyond menarche lasting for at least 6 months. Ambiguous and inconsistent use of terminology and definitions to characterize AUB in the past decades necessitated a new, consensus-based approach to nomenclature and AUB evaluation. This led to the International Federation of Gynecology and Obstetrics (FIGO) System 1 in 2007, which standardized nomenclature, set parameters, and defined normal and abnormal bleeding based on the 5th to 95th percentile data from available large-scale epidemiologic studies. FIGO System 1, endorsed by several national and international societies, improved worldwide communication among educators, clinicians, and researchers. FIGO System 2, published in 2011, focused on classifications of AUB etiology into structural and nonstructural entities using the PALM-COEIN (polyp[s], adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic, and not yet classified) classification system. The PALM-COEIN classification is facilitated by a complete patient history combined with appropriate imaging, histopathologic analysis, or laboratory evaluation to ensure accurate diagnostic and treatment approaches to AUB. Herein we present the systematic evaluation of AUB.

Asymptomatic Bacteriuria in Pregnancy Complicated by Pyelonephritis Requiring Nephrectomy.

Routine prenatal care in the United States includes screening for asymptomatic bacteriuria (ASB), which occurs in 2 to 7 percent of pregnant women and can cause urinary tract infection and pyelonephritis. We present the case of a pregnant woman affected by multidrug resistant Klebsiella induced ASB during her prenatal screen, which was untreated due to a repeat urine culture showing mixed flora; subsequently, the patient's postpartum course was complicated by pyelonephritis and perinephric abscess, concluding in a radical nephrectomy. Current recommendations are to treat ASB after two consecutive voided urine cultures showing the same bacterial strain in quantitative counts of =/> 10(5) colony forming units (cfu)/mL or a single-catheterized specimen with quantitative count of =/> 10(2) cfu/mL. For women with ASB in their prenatal screen or other high risk factors, consideration should be given to testing urine cultures every trimester until the completion of pregnancy to prevent the complications of persistent bacteriuria.

Vulvovaginal Issues in Mature Women.

Mature women often present with symptomatic vulvovaginal atrophy and vulvar dermatoses, causing noncoital pain, dyspareunia, and sexual changes. Diagnosis of these conditions can be challenging, and long-term management is required to decrease morbidity and enhance quality of life. Vaginal estrogen therapies remain safe and effective for treating symptomatic vulvovaginal atrophy. A vulvar biopsy is easy to perform and generally well tolerated when indicated for the diagnosis of lichen simplex chronicus, lichen sclerosus, and lichen planus. Therapy with moderate- to high-potency corticosteroids is effective for these frequently debilitating conditions.

Oral Progestogens Versus Levonorgestrel-Releasing Intrauterine System for Treatment of Endometrial Intraepithelial Neoplasia.

BACKGROUND: Limited therapeutic guidelines exist regarding medical therapy, ideal dosing, duration of therapy, or recommendations for timing of endometrial reassessment for women with endometrial intraepithelial neoplasia (EIN) who desire fertility preservation or who are not optimal surgical candidates. We aimed to determine the effectiveness of oral progestogens (OP) versus the levonorgestrel-releasing intrauterine system (LNG IUS) in the medical treatment of EIN. METHODS: We retrospectively identified women with EIN at our institution from 2007 through 2014 and compared the outcomes of those treated with OP versus LNG IUS. RESULTS: Among 390 women, 296 were initially treated with OP and 94 with LNG IUS. Baseline characteristics of the patient groups were comparable, except for higher median body mass index in the LNG IUS group versus the OP group (37 kg/m2 vs. 31 kg/m2; p < 0.001). Among 332 women with follow-up endometrial biopsies (263 OP and 69 LNG IUS), EIN subcategory 1 (benign endometrial hyperplasia) resolved in 83% and 87% of patients, respectively (p = 0.31). Rates of resolution of EIN subcategory 2 (endometrial intraepithelial neoplasia) were also similar between groups (68% vs. 62%; p = 0.82). In women with EIN subcategory 3 (endometrial adenocarcinoma), 22% of those using LNG IUS and one of two women treated with OP had resolution of disease as of last follow-up. CONCLUSIONS: OP and LNG IUS offer similar endometrial protection for women with EIN. LNG IUS offers convenience, minimal adverse effects, reversibility, and long-term endometrial protection.

Oral and vulvar changes in pregnancy.

The endocrinologic, immunological, and vascular changes that occur during pregnancy are far-reaching. These systemic factors produce profound local impact on the physiology and pathology of the oral cavity, vagina, and vulva. Physiological changes can be expected and tolerable or of such severity that they are viewed as pathological. Existing disease can be exacerbated and dermatoses specific to pregnancy can erupt. Each of these conditions can pose potentially challenging treatment considerations.

Female Sexual Function Improves After Endometrial Ablation.

BACKGROUND: Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. METHODS: Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF-12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. RESULTS: A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 (p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 (p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF-12 scores improved for global physical function (p < .001) and mental function (p = .002). CONCLUSIONS: Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.

Characterization of the relationship between joint laxity and maternal hormones in pregnancy.

OBJECTIVE: To evaluate peripheral joint laxity during pregnancy and to correlate changes with serum cortisol, estradiol, progesterone, and relaxin. METHODS: Forty-six women with first-trimester singleton gestations consented to participate in this longitudinal observational study. Bilateral wrist laxity measurements (flexion-extension and medial-lateral deviation) were made using a clinical goniometer, and serum levels of cortisol, estradiol, progesterone, and relaxin were determined during each trimester of pregnancy and postpartum. Patients were also screened for subjective joint complaints. Statistical analysis included Student t test, analysis of variance, and linear regression analysis. RESULTS: Eleven women (24%) were excluded from the study after spontaneous first-trimester pregnancy loss. Fifty-four percent (19 of 35) demonstrated increased laxity (10% or higher) in either wrist from the first to the third trimester. Although serum levels of cortisol, estradiol, progesterone, and relaxin were significantly elevated during pregnancy, no significant differences in these levels were noted between those who became lax during gestation and those who did not. Linear regression analysis of wrist joint laxity and level of serum estradiol, progesterone, and relaxin demonstrated no significant correlation. Wrist flexion-extension laxity, however, did significantly correlate with level of maternal cortisol (r = 0.18, P =.03). Fifty-seven percent of women developed subjective joint pain during pregnancy, which was not associated with increased joint laxity, but was associated with significantly increased levels of estradiol and progesterone. CONCLUSION: Peripheral joint laxity increases during pregnancy; however, these changes do not correlate well with maternal estradiol, progesterone, or relaxin levels.

Current issues in contraception.

Contraceptive management in women should take into account patient lifestyle and coexisting medical issues as well as method safety, efficacy, and noncontraceptive benefits. This review focuses on common and timely issues related to contraception encountered in clinical practice, including migraine headaches and associated risk of ischemic stroke, the use of combined hormonal contraception along with citalopram and escitalopram, contraceptive efficacy and safety in the setting of obesity, contraceptives for treatment of menorrhagia, the association of intrauterine contraception and decreased risk of cervical cancer, and the association of venous thromboembolism and combined hormonal contraception. Recent trends supporting the use of long-acting reversible contraception are also reviewed.

Association of body mass index with removal of etonogestrel subdermal implant.

BACKGROUND: Bleeding irregularities represent the most common etonogestrel subdermal implant (ESI) removal indication. STUDY DESIGN: ESI placements (n=304) from June 2007 to April 2011 were grouped by removal indications. Group characteristics were compared using one-way analysis of variance, Kruskal-Wallis and χ(2) test. RESULTS: Of 304 insertions, 30.6% reported irregular bleeding. Removal indications included bleeding (Group 1, n=50), side effects (Group 2, n=17) and desired pregnancy/no need (Group 3, n=25). Group 4 kept (n=198) or reinserted (n=14) ESI. Median body mass index was lower for Group 1 compared to other groups (p=.012). Group 3 was older than Group 1 or 4 (p=.021), and more likely parous (p<.001) and postpartum (p=.001) than other groups. Lactational placement was more common in Group 3 than 4 (p<.001). Obese women were 2.6 times less likely to remove ESI for bleeding vs. normal-weight or overweight women (95% confidence interval, 1.2-5.7; p=.014). CONCLUSIONS: After adjusting for age and parity, obese women were less likely to have ESI removal for bleeding.