Structure of Epithelial and Stromal Compartments of Vulvar and Vaginal Tissue From Women With Vulvo-Vaginal Atrophy Taking Ospemifene.

INTRODUCTION: Vulvo-vaginal atrophy affects the daily lives of most post-menopausal women. We know that ospemifene intake can induce vaginal epithelial improvements within a few weeks; however, direct evidence of the effects of ospemifene on the human vulva and on connective tissue of both the vagina and vulva are lacking. AIM: To evaluate the changes induced by ospemifene on epithelium thickness, glycogen content proliferation index, collagen content, and type I/III collagen ratio in vulvar and vaginal tissue of post-menopausal women. METHODS: 20 women who attended our gynecologic clinic for planned surgery were recruited for the study. 11 subjects were taking ospemifene at the time of inclusion, and 9 subjects who were not taking ospemifene were selected as control group. Vaginal and vulvar biopsies were taken during surgery. Histological features and glycogen content were evaluated by standard hematoxylin-eosin and periodic acid-Schiff staining, total collagen and collagen type I/III ratio were evaluated by hydroxyproline assay and Sirius red staining, while the expression of Ki67 was evaluated by immunohistochemistry. MAIN OUTCOME MEASURE: We analyzed histological features of the epithelial and stromal layer of the vaginal and vulvar vestibule mucosa. RESULTS: Vaginal and vulvar biopsies from women taking ospemifene showed an increased epithelium thickness, glycogen content, and proliferation index compared with the control group. Collagen content was also higher in women taking ospemifene, while an increased ratio between type I and III collagen fibers was found only at vaginal level. CLINICAL IMPLICATIONS: Our study shows that the effectiveness of ospemifene on vaginal tissue also extends to the vulvar vestibule. STRENGTH & LIMITATIONS: This study provides direct evidence of the impact of ospemifene on vaginal and vulvar tissue. A specifically designed longitudinal study may further support our findings. CONCLUSION: Ospemifene intake is associated with a marked improvement of various morphological and physiological features of both vaginal and vulvar vestibule epithelium, including the collagen content of the tissues. Alvisi S, Baldassarre M, Gava G, et al. Structure of Epithelial and Stromal Compartments of Vulvar and Vaginal Tissue From Women With Vulvo-Vaginal Atrophy Taking Ospemifene. J Sex Med 2018;15:1776-1784.

Atypical morphology of anogenital warts is not a marker of atypical histology or of infection to the high-risk human papillomavirus genotypes.

BACKGROUND: The clinical morphology of anogenital warts may vary from flat, filiform, papular, or verrucous to giant condyloma acuminatum. Clinically atypical-looking genital warts may alarm the clinician because of their suspected malignant potential, which may cause anxiety, often leading to aggressive interventions. OBJECTIVE: To study if clinically atypical-looking anogenital warts are more likely to be premalignant or malignant as compared to typical warts. METHOD: Data of 41 (37 males, 4 females) patients with anogenital warts was retrospectively analyzed. After a detailed literature review and in-house discussions, criteria for anogenital warts with typical and atypical clinical morphology were defined. Clinical photographs were independently reviewed by three dermatologists, and human papillomavirus (HPV) genotyping results, histological evaluation, and immunohistochemical analysis for p53 expression were evaluated. RESULTS: Fifteen (36.6%) anogenital warts were classified as atypical by at least two of three blinded dermatologists. The histological examination showed mitotic figures in 31/41 (75.6%) specimens, dysplasia in 14/41 (44.1%) specimens, and p53 positivity in 34/41 (82.9%) specimens. There was no significant difference in the high-risk HPV genotyping (P = 0.67), frequency of dysplastic changes on histology (P = 0.19), and immunohistochemistry with p53 (P = 0.08) between clinically typical and atypical-appearing anogenital warts. Similarly, no significant difference was found in the frequency of dysplastic changes (P = 0.67) or p53 expressions (P =0.41) based on the HPV genotypes. CONCLUSIONS: The atypical clinical morphology of anogenital warts may not be a marker of increased malignant potential. High-risk HPV genotypes do not have a statistically significant association with dysplasia or positive immunohistochemistry with p53.

Pigmented apocrine hamartoma of the vulva: A case report.

We herein report a patient who clinically presented with a pigmented, flat plaque in the vulvar area. Histological examination showed a benign lesion mainly composed of tubular and cystic glands with apocrine differentiation. The most striking histological feature was the deposition of finely granular melanin pigment both in the epithelial cells and in the luminal surface of the glands. In addition, Melan-A immunostaining showed the presence of numerous melanocytes within the lesion suggesting that the pigment deposition was secondary to colonization of the lesion by melanocytes. We therefore diagnosed this lesion as "pigmented apocrine hamartoma." To the best of our knowledge only 3 cases of pigmented apocrine hamartoma have been reported in the literature so far.

Androgens in women are essentially made from DHEA in each peripheral tissue according to intracrinology.

The objective is to review how the cell-specific amounts of intracellular androgens are all made in women from circulating dehydroepiandrosterone (DHEA) in each peripheral tissue, independently from the rest of the body. Following 500 million years of evolution, approximately three dozen cell-specific intracrine enzymes have been engineered in human peripheral tissues whereby the inactive sex steroid precursor DHEA mainly of adrenal origin is transformed into the appropriate minute intracellular amounts of androgens. These intracellular androgens are inactivated in the same cells, with no biologically significant release of active androgens in the circulation. The best estimate is that approximately 50% as much androgens are synthesized in women, compared to men of the same age. The problem with DHEA, however, the exclusive source of androgens in women of all ages, is that DHEA secretion has already decreased by an average of 60% at time of menopause and continues to decrease thereafter. The human-specific and highly sophisticated mechanisms of intracrinology permit each cell to control androgen availability according to its own needs independently from the remaining of the body. Such a mechanism is completely different from classical endocrinology well understood in men where testosterone of testicular origin is transported through the blood and has indiscriminate access to the androgen receptor (AR) in all AR-containing cells of the body. In men, both the endocrine and intracrine mechanisms are in operation while, in women, only the intracrine mechanisms responsible for intracellular formation from DHEA provide androgens.

[Establishment of a SD rat model of vulvar lichen simplex chronicus and detection of the expression of protease activated receptor 2].

OBJECTIVE: To establish a SD rat model of vulvar lichen simplex chronicus (LSC) and investigate the expression of protease activated receptor 2 (PAR2) in the genital skin. METHODS: Seventy female SD rats were randomly divided into group A (blank control group, n=10), group B (with application of acetone solution 3 times per week for 10 weeks, n=10), group C (with chronic mechanical irritation 3 times per week for 10 weeks, n=10), and group D (with topical treatment with 0.5= 7,12-Dimethylbenzanthracene [DMBA] in acetone solution and chronic mechanical irritation 3 times per week for 10 weeks, n=40). The changes of the genital skin changes were observed regularly and the expression of PAR2 in groups A and D was detected with immunohistochemistry, Western blotting and qRT-PCR. RESULTS: In group D, LSC occurred in 23 rats (57.5=) at 8 weeks and in 38 rats (95=) at 10 weeks; 8 rats (20=) showed papilloma at 12 weeks. Acetone treatment or chronic mechanical irritation did not cause LSC in the rats. Immunohistochemistry, Western blotting and qRT-PCR showed significantly increased expressions of PAR2 in group D at both the protein and mRNA levels as compared with those in group A (P<0.05). CONCLUSION: 0.5= DMBA in acetone solution along with chronic mechanical irritation can induce LSC in female SD rats, and PAR2 is closely related with the occurrence and progression of LSC.

Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management.

Genitourinary syndrome of menopause, a new term for a condition more renowned as atrophic vaginitis, is a hypoestrogenic condition with external genital, urological, and sexual implications that affects >50% of postmenopausal women. Due to sexual embarrassment and the sensitive nature of discussing symptoms, genitourinary syndrome of menopause is greatly underdiagnosed. The most up-to-date literature pertaining to clinical manifestations, pathophysiology, etiology, evaluation, and management of genitourinary syndrome of menopause is comprehensively reviewed. Early detection and individually tailored pharmacologic (eg, estrogen therapy, selective estrogen receptor modulator, synthetic steroid, oxytocin, and dehydroepiandrosterone) and/or nonpharmacologic (eg, laser therapies, moisturizers and lubricants, homeopathic remedies, and lifestyle modifications) treatment is paramount for not only improving quality of life but also for preventing exacerbation of symptoms in women with this condition.

Localized amyloidosis of the vulva with and without vulvar intraepithelial neoplasia: report of a series.

Localized primary cutaneous amyloidosis is uncommon in Europe and North America and is infrequently reported in the English literature. The constituents of such deposits have not been previously examined; this series characterizes amyloid deposits in localized vulvar amyloidosis and their association with vulvar intraepithelial neoplasia. All biopsies and excisions of vulva over 18 months were reviewed. Cases with suspected amyloidosis were retrieved after institutional review board approval. Twenty cases mimicking amyloidosis were selected as controls. All study and control cases were stained with Congo red. Four Congo red-positive study cases were studied by liquid chromatography-tandem mass spectrometry. Of 27 Congo red-positive study cases, 25 were then examined by immunohistochemical stains with antibodies to cytokeratin 5 (CK5) and cytokeratin 14 (CK14). Of 149 cases reviewed, 26 localized and 1 systemic vulvar amyloidosis were identified. Liquid chromatography-tandem mass spectrometry analysis of the deposits revealed unique peptide profile consistent with CK5 and CK14. Immunohistochemical staining with antibodies to CK5 and CK14 also detected these components in the deposits. The vulvar deposit of systemic amyloidosis consisted of amyloid light chain (λ)-type amyloid deposit. All control cases were negative for Congo red. Keratin-associated amyloid materials (CK5 and CK14) were found to be unique in localized vulvar amyloidosis. Leakage of keratins from the basal layer of the epithelium into the superficial dermis may have been the possible source of the deposits. It appears to be associated with both high-grade and low-grade vulvar intraepithelial neoplasias and, rarely, lichen sclerosus, seborrheic keratosis, and benign vulvar skin.

Sebaceous hyperplasia of the vulva: a series of cases reporting no association with the Muir-Torre syndrome.

Sebaceous gland hyperplasia is a common skin condition, very rarely reported in the female genital region. We present 13 cases from 12 patients, the first case series of sebaceous gland hyperplasia of the vulva. Differences in age at presentation and clinical presentation compared with classic sebaceous gland hyperplasia from the head and neck region were noted. Also, it was rarely included in the clinical differential diagnosis. Immunohistochemical studies to determine any possible association with the Muir-Torre syndrome were performed and mismatch repair protein loss was not identified.

[Expression of HPV16 E6 protein in nonneoplastic epithelial disorder of the vulva and squamous cell carcinoma of the vulva].

OBJECTIVE: To investigate the expression of high risk human papilloma virus (HPV) 16-E6 protein in non-neoplastic epithelial disorders of the vulva (NNEDV) and squamous cell carcinoma of the vulva (VSCC), and to explore whether HPV16-E6 protein is the etiological factor in NNEDV and its correlation with squamous cell carcinoma of the vulvae. METHODS: We detected HPV16-E6 protein expression in 15 normal vulvae cases, 40 NNEDV cases and 45 VSCC cases by immunohistochemistry SP method. RESULTS: The positive rate of HPV16-E6 in different vulva tissues: was 0% in the normal vulva, 30% in NNEDV and 66.67% in VSCC, respectively. The overall positive rate and two two comparison had statistical significance. In the NNEDV group, the positive rate of squamous hyperplasia type and lichen sclerosus type was 35% and 25%, respectively, with no statistical significance (P>0.05), but higher than that in the normal vulva skin group (P<0.05) and lower than that in the VSCC group (P<0.05). The positive rate of HPV16-E6 in VSCC was 66. 67%. The positive rate increased with the clinical stage. The positive rate between Phase I and Phase II, and that between Phase I and Phase III had statistical significance (P<0.017), but that between Phase II and Phase III had no statistical significance (P>0.017). The positive rate gradually decreased with the tumor differentiation. The difference in well-differentiated and poorly differentiated, moderately and poorly differentiated had statistical significance (P<0.017), but that of well-differentiated and moderately differentiated had no statistical significance (P>0.017). The positive rate of lymph node metastasis VSCC was significantly higher than that of non-lymph node metastasis VSCC (P<0.05). CONCLUSION: HPV infection may be an etiological factor for NNEDV. The rise of HPV16-E6 positive rate may be related to the occurrence and development of vulvar squamous cell carcinoma.

Localized lymphedema of the vulva: a clinicopathologic study of 2 cases and a review of the literature.

This report describes 2 cases of localized vulvar lymphedema that were diagnosed in 2 morbidly obese women, including a unique case of a massive localized vulvar lymphedema associated with lymphangioma circumscriptum of the vulva. Herein, we also review previously reported cases of vulvar lymphedema and discuss differential diagnostic considerations. Our review of the recent literature showed 17 cases that we considered approximately similar, reported under the appellations "vulvar lymphoedematous pseudotumor," "massive vulval edema," "vulvar hypertrophy with lymphedema," and "localized lymphedema (elephantiasis)." The patients ranged in age from 19 to 59 years (average 38.5 yrs), and typically presented with papillomatous plaques, skin polyps, generalized vulvar enlargement, or massive pedunculated masses that had been present for durations that ranged from 3 months to 36 years. The average lesional size was 6.1 cm (range: 0.6 - 45 cm), and 10 (59%) of the 17 cases were 3 cm or less. Excisions were generally curative, although persistent or recurrent disease was reported in 3 cases. The patients were overweight in 9 (75%) of the 12 cases in which the patient weight was noted, and 2 others had chronic immobilization. Stromal edema was the only morphologic finding that was uniformly seen in all 17 cases. However, the following morphologic features were identified in significant subsets: multinucleated giant cells, dermal fibrosis, dermal lymphangiectasia, dermal chronic inflammation, perivascular chronic inflammation (superficial and/or deep), hyperkeratosis, acanthosis, and blood vessels of varying calibers. Several attributes of localized vulvar lymphedema may cause them to closely mimic aggressive angiomyxoma, a differential diagnosis that is herein discussed in detail. Localized vulvar lymphedema may also be a small lesion, and can potentially mimic other myxedematous tumors of the vulvovaginal region. The strongest clinical association is with obesity. The term "localized vulvar lymphedema" is an appropriate generic descriptor for the spectrum of lesions whose fundamental and underlying etiology is thought to be chronic lymphedema.

Reactive fibroblastic and myofibroblastic proliferation of the vulva (Cyclist's Nodule): A hitherto poorly described vulval lesion occurring in cyclists.

Perineal nodules occurring in male cyclists are reported in the literature, although the histologic features are not extensively documented. There has been little description of similar lesions in the female population. We describe 4 cases in which a vulval nodule or swelling developed in competitive female cyclists aged 15 to 45 years. The lesions were unilateral and occurred on the right or left labium majus (2 cases each). The histologic features were similar in all cases and consisted of a haphazard admixture of adipose tissue, variably cellular hyalinized tissue containing bland spindle-shaped fibroblasts, blood vessels, and nerve fibers. In some areas, thick cords of fibrous tissue imparted a keloid-like appearance. Other histologic features included plump mesenchymal cells with round or ovoid nuclei and abundant eosinophilic cytoplasm resulting in an epithelioid, plasmacytoid, or ganglion-like appearance (2 cases), a lymphocytic infiltrate around blood vessels (3 cases), foci of fat necrosis (1 case), and collections of elastic fibers (2 cases). One case recurred, the histologic features of the recurrent lesion being identical to the original. The overall morphologic appearances, especially in the cases with plump mesenchymal cells, bore some resemblance to proliferative fasciitis. Immunohistochemically, the cells were estrogen receptor positive and the plump mesenchymal cells were smooth muscle actin positive, in keeping with myofibroblasts. Desmin, S100, CD34, and HMGA2 were negative. Pathologists should be aware of this pseudoneoplastic lesion occurring on the vulva, which arises in a specific clinical setting and has the potential to be misdiagnosed as a variety of other mesenchymal lesions. We term this lesion as reactive fibroblastic and myofibroblastic proliferation of the vulva or "cyclist's nodule."

Extramammary Paget's disease with the appearance of a nodule: a case report.

BACKGROUND: Extramammary Paget's disease (EMPD) remains a rare condition with only a limited number of cases reported in the literature. EMPD is mainly composed of intraepidermal Paget cells, and possesses variable clinical behaviors and histological appearances, leading to difficulty in the diagnosis of this disease. CASE PRESENTATION: We here report a case of primary EMPD with the appearance of a nodule on the background of erythema. Histological assessment showed Paget cell infiltration throughout the epidermis with dermal spread. Using immunohistochemistry, the expressions of CK7, CK19, CK20, GCDFP-15, CEA, S-100 protein and bcl-2 were examined to elucidate the cellular differentiation of the carcinoma. CONCLUSION: According to the histological assessment, this case was diagnosed as primary EMPD with carcinoma cells invading into the dermis, but without lymph node infiltration.

Effectiveness of photodynamic therapy in the treatment of lichen sclerosus: cell changes in immunohistochemistry.

BACKGROUND: Vulvar lichen sclerosus (LS) affects primarily women at postmenopausal age and its background remains unknown. One of the treatment modalities is photodynamic therapy (PDT). The aim was to investigate the efficacy of PDT in women with LS and the analysis of protein expression before and after PDT. MATERIAL AND METHODS: From 04.2006-01.2008 28 women, with LS underwent photodynamic diagnosis and next PDT: six-courses every second week with using 5-aminolevulinic acid (ALA) as a photosensitizer. Punch biopsies were taken before and after treatment and immunohistochemistry was done with Ki67,CD44,CD34 and CD3. RESULTS: Before PDT all patients suffered from pruritus and after in 89.3% the relief was noted. The histological examination showed that 35.7% patients hadn't LS after therapy completion. Anti-CD44 staining intensities was scored qualitatively - there were no statistical difference at the expression of protein CD44 in the epidermis (p>0.05) before and after therapy. Microvessel density was assessed at the hot spots, marked with anti-CD34. Statistical difference in AVD before and after therapy: (p<0.05). The staining intensity of Ki-67 didn't differ before and after PDT (p>0.05). The expression of CD3 on T lymphocytes showed statistical difference of the lymphocytic infiltration before and after PDT ( p<0.05). CONCLUSION: The immunohistochemical staining in vulvar LS showed increasing microvessel density and decreasing lymphocytic infiltration. There were a clinical, and less histological improvement in patients with LS. We suggest that the photodynamic therapy is an effective, alternative treatment in some but not all patients with LS. Therefore, further studies are needed.

Acquired lymphangiectasia ('lymphangioma circumscriptum') of the vulva: a report of eight cases.

AIMS: To present the clinico-pathological findings of eight cases of acquired vulval lymphangiectasia (AVL) with discussion of the terminology and differential diagnosis. METHODS: Vulvectomy or biopsy specimens from eight patients with AVL were reviewed. All patients had undergone surgery, lymphadenectomy and/or radiotherapy, most commonly for carcinoma of the cervix, up to 26 years prior to presentation with the lymphangiectatic lesions. Immunohistochemistry for CD31, CD34, D2-40, p53 and p16 was performed in each case. RESULTS: The original clinical and pathological diagnoses were most frequently 'lymphangioma circumscriptum' but viral infection was considered in some cases. All specimens showed dermal lymphangiectasia associated with marked reactive epidermal hyperplasia. The lymphatic endothelial cells showed CD31 and D2-40 expression but CD34 was negative. The keratinocytes showed focal p53 immunoreactivity in four cases. CONCLUSIONS: AVL is the preferred nomenclature for the lesions presented herein. The clinical and histological features usually are characteristic but the differential diagnosis may include condyloma and differentiated type vulval intraepithelial neoplasia (VIN). Immunohistochemistry may be helpful but lack of CD34 expression should be noted and may prove useful in the differential diagnosis of other vulval vascular lesions. Focal p53 protein immunoreactivity should not be considered indicative of differentiated type VIN in this clinical setting.

The pathomorphology of Bartholin's gland. Analysis of surgical data.

Medline data did not reveal any statistical approach to Bartholin's gland pathomorphological lesions, especially when the social aspect was considered. Objectives. To complete knowledge and data according to this subject on the basis of own surgical material analysis. Microscopic examinations of histopathological 5 microm thick specimens stained with hematoxylin-eosin and in selected cases with histochemical and immunohistochemical methods on 104 Bartholin's glands taken from 103 female patients in age of 39.4 +/- 9.6. Retention cysts, suppurating lesions (abscesses), extrauterine endometriosis and neoplasms were separated from obtained samples. Localization of lesions, the patients' age and education status were determined. P < 0.05 was considered as statistically significant. Retention cysts were observed in 84.6% of cases, abscesses in 10.6%, extrauterine endometriosis in 2% and neoplasms in nearly 3% of patients. In 54.1% of cases the lesion was localized on the left side, in 45.9% on the right. 17.2% of female patients presented with university education, 29.9% with elementary education, while 52.9% with secondary education. The average age of operated patients amounted to 33 +/- 9.8 years in case of university education, being significantly lower as compared to the average age of secondary (40.5 +/- 7 years) and elementary (42.4 +/- 12 years) education (p < 0.01 and p < 0.02 respectively). 47.7% of retention cysts demonstrated various degrees of inflammatory infiltration. However, the anatomical variability of the ductal and glandular epithelium was higher in cases of non-inflammatory cysts. Considering three Bartholin's gland neoplasms, two were diagnosed as adenocarcinomas and one as a fibromyoma. All of them were observed in female patients with a rare blood type (twice Rh-minus and once AB Rh-plus). There was no significant relationship between the type of pathomorfological lesions and age of operated patients, in spite of the fact that the lowest mean age was observed in woman with endometriosis while the highest in those with neoplasms. The pathology of Bartholin's gland mostly concerns female patients with secondary education. However, early diagnosis is associated with patients with university education. Thus, further investigations considering the statistical analysis of Bartholin's gland neoplasms in order to determine the possible relationship between blood type antigens and neoplasm development are required.

Is localized, provoked vulvodynia an inflammatory condition?

OBJECTIVE: To perform a pilot study to investigate the relationship between localized, provoked vulvodynia of the vestibule and inflammatory cytokine expression. STUDY DESIGN: Women with a diagnosis of localized, provoked vulvodynia had tissue samples taken for vulvar expression of Interleukin 1alpha and 1beta and tumor necrosis factor alpha and compared to those of a control group. RESULTS: The study group did not show a significant increase in expression of inflammatory markers. CONCLUSION: There was no evidence in this study that localized, provoked vulvodynia is an inflammatory condition, as previously thought. This may be helpful in explaining why some women are resistant to medical or antiinflammatory treatment and may allow treatment to be prescribed more effectively.

[Expression of cyclin D1 and p16 protein in vulvar white lesion].

OBJECTIVE: To investigate the relationship between cell cycle protein (cyclin D1 and p16) expression and vulvar white lesion. METHODS: Biopsies from 34 cases with vulvar white lesion, including 12 cases with lichen sclerosus (LS), 18 with squamous hyperplasia (SH) and 4 SH accompanied with LS, were examined for protein expression of cyclin D1 and p16 using immunohistochemical techniques. Normal vulvar tissues from 11 patients with other benign gynecologic diseases were used as control. RESULTS: Fifty-six percent of patients with vulvar white lesion were immunopositive for cyclin D1 protein, which was significantly higher than that of control group (9%, P < 0.05); but there was no significant difference between LS (58%) and SH patients (50%, P > 0.05) in expression of cyclin D1 protein. Immunopositive expression of p16 protein in patients was 6%, with no significant difference from the control group (0, P > 0.05). CONCLUSIONS: Cyclin D1 and p16 are important factors modulating cell cycle. The interrupt of balance between these two factors derived from abnormal expression of cyclin D1 may be one of the causes of vulvar white lesion.