Health economic evaluation of a randomized controlled trial (EMBLA study), an internet-based treatment for provoked vulvodynia.

Internet-based treatment (IBT) for provoked vulvodynia (PVD) may reduce pain during intercourse and increases pain acceptance. However, a there is still a knowledge gap regarding the cost-effectiveness of IBT for PVD. The aim of this study was to perform a health economic evaluation of guided internet-based intervention for PVD as an addition to standard treatment. The sample consisted of 99 women with a PVD diagnosis. Healthcare related costs, health-related quality of life, and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were analyzed. After the IBT, the intervention group had fewer visits to a midwife than the control group (p = 0.03), but no between-group differences were found for visits to other professionals, treatment length, health-related quality of life, QALYs, and costs for treatment. It was estimated a cost of 260.77 € for a clinical meaningful change in pain acceptance. Internet-based treatment as add-on to clinical treatment may lower number of visits to a healthcare.

The vulval vestibular mucosa-morphological effects of oral contraceptives and menstrual cycle.

BACKGROUND: An erythematous and hypersensitive vestibular mucosa has been observed during the use of combined oral contraceptives (COC). Hormonal effects on the vestibular morphology have not been studied. OBJECTIVES: Our aim was to evaluate the morphology of the vulval vestibular mucosa during the influence of COC and during the menstrual cycle. METHODS: Forty-five healthy women (20 using COC and 25 not using COC) were included. A 6-mm punch biopsy was obtained from the right posterior vestibule on days 7-11 of the menstrual cycle. A corresponding biopsy was taken 2 weeks later in 16 women without COC. The epithelial morphology was estimated by measuring interdermal papilla distance, dermal papilla to surface, from basal layer to surface and width of dermal papillae. A histopathological assessment was made. RESULTS: The vulval vestibular mucosa of women using COC displayed a larger distance between the dermal papillae (P = 0.04) and a larger space from the dermal papillae to the epithelial surface (P = 0.03) compared with controls in the follicular phase. Women without COC displayed a larger interdermal papilla distance in the luteal phase compared with the follicular phase, P = 0.02. Histopathology showed more superficial blood vessels in the COC users (P < 0.01). CONCLUSIONS: The vulval vestibular mucosa of women with COC display an altered morphological pattern with shallow and sparse dermal papillae compared with the follicular phase. Similar findings are seen in women without COC during the luteal phase which indicate a gestagenic effect on the mucosa. Associations between the morphological pattern and changes in mucosal mechanical sensitivity require further studies.

The expression of cyclooxygenase 2 and inducible nitric oxide synthase indicates no active inflammation in vulvar vestibulitis.

BACKGROUND: Although women with vulvar vestibulitis syndrome have principal symptoms of inflammation such as local erythema and pain in the mucosa around the vaginal introitus, it is not clear if vestibulitis is an inflammatory condition. Cyclooxygenase 2 and inducible nitric oxide synthase are known to be upregulated during inflammation. The aim of the present study was to analyze the expression of these enzymes in the vestibular mucosa in order to evaluate the inflammatory activity in the tissue. METHODS: Ten women fulfilling Friedrich's criteria of vulvar vestibulitis syndrome and ten control subjects were included in the study. Punch biopsies were obtained from the vestibular mucosa for analysis of cyclooxygenas 2 and inducible nitric oxide synthase, using indirect immunohistochemistry and Western dot-blot analyses. RESULTS: Both methods used showed low expression of cyclooxygenas 2 and inducible nitric oxide synthase in the vestibular mucosa of all women. There was no difference observed between the groups. CONCLUSIONS: There is a low expression of the inflammatory markers cyclooxygenas 2 and inducible nitric oxide synthase in the vestibular mucosa of women with vulvar vestibulitis syndrome as well as in healthy control subjects. The results indicate no active inflammation present and imply that topical corticosteroids in the treatment of vulvar vestibulitis are unfounded.

Increased blood flow and erythema in the posterior vestibular mucosa in vulvar vestibulitis(1).

OBJECTIVE: To evaluate vascular changes as a possible underlying cause of mucosal erythema in women with vulvar vestibulitis. METHODS: Laser Doppler perfusion imaging was used to map the superficial blood flow in the vestibular mucosa in 20 women with vestibulitis and in 21 healthy control subjects. A possible correlation between perfusion values and graded erythema (1-5) around the vaginal introitus was analyzed. Changes in microvascular density in the posterior part of the mucosa were investigated in sections from ten patients and ten controls by a computer-assisted image-processing program. Induced vasoconstriction of terminal arterioles in the same posterior area was also studied. RESULTS: Significant increases in perfusion values were registered in the posterior parts of the vestibular mucosa in patients compared with controls. The highest blood flow was registered in the posterior fourchette. The most pronounced erythema was also located in the posterior vestibule in the patients. However, there was no significant correlation between perfusion values and degree of erythema in the same individual. The microvascular density or the ability of vestibular arterioles to constrict did not differ between patients and controls. CONCLUSION: Women with vestibulitis have an increased superficial blood flow and erythema in the posterior parts of the vestibular mucosa. The increased perfusion, most probably caused by a neurogenic vasodilatation contributes to, but does not fully explain the erythema. Atrophic changes of the surface epithelium should also be considered in the evaluation of an erythema.

[Vulvar vestibulitis is a condition with diffuse etiology]. / Vulvavestibulit svårbehandlat tillstånd med oklar etiologi.

Vestibulum vulvae is covered by a sensitive mucosa of endodermal origin. The pain syndrome "vulvar vestibulitis", which is frequently occurring in young women, gives rise to intensive pain during sexual intercourse. The diagnosis requires at least six months duration of provoked pain and the presence of red areas in the vestibulum, which are intensely painful to the touch. There is an increased intraepithelial innervation but no active inflammation. The etiology of vulvar vestibulitis is probably multifactorial. Possible trigger mechanisms include repeated use of antibiotics and local treatment of Candida and HPV infections in combination with the use of hormonal contraceptives, frequent use of local substances that may be irritative, lack of arousal, vaginismus and tense pelvic floor muscles. Spontaneous recovery is possible if all treatment is suspended. Other regimens include biofeedback, psychotherapy, tricyclic antidepressants and surgery. There is a 80 per cent success rate after surgery in carefully selected patients.

Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome.

Women with vulvar vestibulitis syndrome (VVS) have a distinct burning pain provoked by almost any stimuli in the area around the vaginal introitus. In a previous study we observed an increased number of intraepithelial free nerve endings in women with VVS. The aim of the present study was to neurochemically characterize the superficial nerves in the vulvar vestibular mucosa of women with VVS. Immunohistochemical methods were used to detect neuropeptides normally found in various types of nerve fibers. Calcitonin gene-related peptide, which is known to exist in nociceptive afferent nerves, was the only neuropeptide detected in the superficial nerves of the vestibular mucosa. These findings confirm our previous theory that the free nerve endings within the epithelium are nociceptors.

Increased intraepithelial innervation in women with vulvar vestibulitis syndrome.

Women with vulvar vestibulitis syndrome (VVS) suffer from severe pain and discomfort in the area around the introitus at almost any stimulus that causes pressure within the vestibule. In spite of the severe sensory symptoms present in these women, the influence of the peripheral nerves in the vulvar vestibulum has not been clarified before. In this study the nerve supply in the vestibular mucosa in women with VVS and in healthy women free from vulvar symptoms has been revealed by PGP 9.5 immunohistochemistry. The results show a significant increase in the number of intraepithelial nerve endings in women with VVS, indicating an alteration in the nerve supply in the afflicted area.