Human papillomavirus in vulvar vestibulitis syndrome.

OBJECTIVE: To investigate the prevalence of human papillomavirus (HPV) in patients with vulvar vestibulitis syndrome by using a recently developed polymerase chain reaction (PCR) primer set that detects known papillomavirus types. STUDY DESIGN: We retrospectively identified 38 patients with vulvar vestibulitis who underwent therapeutic surgical excision of the vestibule. Eleven controls without vestibulitis who underwent vestibular excision for conditions unrelated to HPV infection were identified prospectively. Surgical specimens were examined for the presence of HPV DNA by PCR amplification. DNA sequencing was used to determine HPV type. RESULTS: The prevalence of HPV among patients with vestibulitis was 21% vs. 36% among controls. Group B HPV types accounted for 4 of the 10 (40%) HPV types found in patients with vestibulitis. Overall, in both patient and control samples, a spectrum of HPV types was identified, encompassing many branches of the HPV phylogenetic tree. No etiologic association was apparent. CONCLUSION: This study did not support an association of HPV with vulvar vestibulitis. The low rate of observed infection in women with and without vestibulitis and the diversity of HPV types identified suggest incidental virus carriage rather than direct cause and effect. The underlying cause of this debilitating condition remains unknown.

Radiofrequency global endometrial ablation followed by hysteroscopic sterilization.

STUDY OBJECTIVE: To describe the feasibility of performing Essure hysteroscopic sterilization immediately after NovaSure global endometrial ablation (GEA). DESIGN: Descriptive feasibility study (Canadian Task Force classification III). SETTING: Midwestern United States academic medical center. PATIENTS: Twenty-five women (aged 35-49 years) with menorrhagia who elected GEA treatment and requested concurrent permanent sterilization. INTERVENTIONS: NovaSure GEA followed immediately by Essure hysteroscopic sterilization. Patients returned 3 months after the procedure for hysterosalpingography (HSG) to document tubal occlusion. MEASUREMENTS AND MAIN RESULTS: The inserts were placed successfully in all 25 patients; 21 returned for 3-month follow-up HSG, as recommended. Bilateral tubal occlusion was documented at 3 months in 19 patients (90%) and unilateral occlusion in 2 patients. Six-month postprocedural HSG in these 2 patients documented bilateral tubal occlusion. Hysterosalpingography was not performed in 4 patients. In all 21 patients with appropriate follow-up, complete occlusion was documented, and the ability to perform or interpret HSG was not affected by endometrial ablation. CONCLUSION: Essure hysteroscopic sterilization can be safely performed after NovaSure GEA. Intrauterine synechiae do not appear to adversely affect the ability to perform HSG at 3 months or to document tubal occlusion.

Long-term fracture risk among women with proven endometriosis.

OBJECTIVE: To determine whether women with pelvic endometriosis are at increased fracture risk. DESIGN: Historical cohort study. SETTING: Population-based investigation using the data resources of the Rochester Epidemiology Project. PATIENT(S): From Olmsted County, Minnesota, 987 women with endometriosis that was first surgically visualized or histologically proven in 1970-1989. INTERVENTION(S): None, observational study. MAIN OUTCOME MEASURE(S): Follow-up for fractures through complete inpatient and outpatient community medical records. RESULT(S): In 17,408 person-years of follow-up, 256 women experienced 449 different fractures. The cumulative incidence after 20 years (30.8%) was not elevated relative to that expected (30.6%). The independent predictors of any fracture included age (hazard ratio [HR] per 10 years: 1.61; 95% confidence interval [CI] 1.42-1.84]), corticosteroid use (HR: 2.78; 95% CI 1.48-5.24), prior hip, spine, or forearm fracture (HR: 1.82; 95% CI 1.10-3.02), and use of the selective estrogen receptor modulators, tamoxifen or raloxifene (HR: 4.34; 95% CI 2.14-8.81); physical activity was protective (HR: 0.40; 95% CI 0.18-0.88). There was no significant influence on fracture risk of surgery or other medical treatments for endometriosis. CONCLUSION(S): Despite reported adverse effects of treatment on bone density, there was no overall increase in long-term fracture risk in this unselected cohort of women with proven endometriosis.

Incidence and characterization of diagnosed endometriosis in a geographically defined population.

OBJECTIVE: We examined whether widespread use of laparoscopy was accompanied by increased diagnosis of asymptomatic endometriosis, inflated rates of diagnosis, or changes in the clinical spectrum of disease. DESIGN: Population-based cohort. SETTING: Olmsted County, Minnesota. PATIENT(S): All participants were women residents, aged > or =15 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): We estimated the likelihood that women with a surgical procedure during which endometriosis could be visualized would receive a surgical diagnosis, as well as the proportions of all diagnoses, regardless of setting, that were [1] assigned without surgery, [2] refuted by surgery, [3] surgically confirmed, and [4] asymptomatic. The incidence of diagnosed endometriosis for 1987 to 1999 was compared with published rates for 1970 to 1979. RESULT(S): Of 8,229 women aged > or =15 years with > or =1 surgery during which endometriosis could be visualized, 11.5% received a surgical diagnosis of endometriosis. The incidence of diagnosed endometriosis, regardless of setting, was 1.9 per 1,000 person-years (10% were without relevant surgery, 6% had surgery but no surgical evidence, 85% had surgical evidence); 85% of surgically confirmed diagnoses had presenting symptoms. Using definitions comparable with those in the 1970 to 1979 study, the 1987 to 1999 incidence was 2.46 per 1,000 versus 2.49 per 1,000 for 1970 to 1979; 88% of symptomatic incident diagnoses were surgically confirmed versus 65% for 1970 to 1979. CONCLUSION(S): Widespread use of laparoscopy does not appear to have contributed to dramatically increased rates of endometriosis diagnoses but rather to a smaller proportion of diagnoses being assigned without surgical confirmation.

Hormone therapy in menopause: the plot thickens.

The termination of one of the trials in the Women's Health Initiative (WHI) study is causing turmoil in women using hormone therapy. Practitioners and patients alike are confronted with conflicting evidence about the safety and effectiveness of both estrogen therapy (ET) and hormone (estrogen/progestin) therapy (HT). Recent investigations of the estrogen receptor, the genome, and cellular cofactors have demonstrated the heterogeneity of molecular response to hormones. This implies a heterogeneous response in the individual as well and casts doubt on the validity of prior research. Recent experiments in monkeys have provided a possible explanation for the adverse effects of HT on the cardiovascular system that were detailed by the Heart and Estrogen/Progestin Replacement Study (HERS) and WHI studies. This article explores nuances of several key studies and discusses potential therapeutic options, including use of lower-dose estrogen, transdermal estrogen, selective estrogen-receptor modulators, and diminished use of progestin.