A Scoping Review of Treatment Outcome Measures for Vulvar Intraepithelial Neoplasia.

OBJECTIVE: The goal of this study is to identify a list of clinician-reported outcome measures (CROMs) and patient-reported outcome measures (PROMs) through a review of published studies reporting on any therapeutic interventions for vulvar intraepithelial neoplasia (VIN). MATERIALS AND METHODS: A systematic search of published studies reporting on any therapeutic interventions for VIN was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to September 20, 2021, based on predetermined study selection criteria. Data were extracted and analyzed by 2 authors independently using Covidence software. RESULTS: Thirty two of 2386 studies identified met study selection criteria. None of the 32 studies provided an explicit definition of VIN treatment "success." The most common CROM was "clinical response to treatment." The most common scale used to measure this outcome was "complete response/partial response/no response"; however, 17 of 23 studies (73.9%) did not define these values. Laboratory CROMs were reported in 12/32 (37.5%) studies. Patient-reported outcome measures were reported in only 10 of 32 studies(31.3%) -the most common PROM was "symptoms." Only 2 of 32 studies measured PROMs related to "quality of life" domains. Adverse events/treatment-related adverse effects were reported in 24 of 32 studies (75%), although 71% of studies provided no details on how these data were collected. CONCLUSIONS: There is a large variation in outcome measures, instruments, and scales used for any clinician-reported treatment outcome such as "clinical response." Most studies do not include patient-reported outcome measures assessing quality of life domains. A Core Outcome Set for the treatment of VIN is needed to improve the quality of VIN research.

A Systematic Review of Risk Factors for Development, Recurrence, and Progression of Vulvar Intraepithelial Neoplasia.

OBJECTIVE: Vulvar intraepithelial neoplasia (VIN) is a premalignant condition with high recurrence rates despite treatment. Vulvar intraepithelial neoplasia develops through separate etiologic pathways relative to the presence or absence of human papillomavirus (HPV) and TP53 mutations. This systematic review was conducted (1) to identify historical risk factors for the development, recurrence, and progression of VIN and (2) to critique these risk factors in the context of advances made in the stratification of VIN based on HPV or TP53 status. MATERIALS AND METHODS: A systematic search was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to July 5, 2021. Three gynecologic oncologists independently evaluated the eligibility of studies based on predetermined inclusion and exclusion criteria, abstracted data, and then analyzed the relevant data. RESULTS: A total of 1,969 studies (involving 6,983 patients) were identified. Twenty-nine studies met inclusion criteria. The quality of evidence was low; primarily level 2b (Oxford Centre for Evidence-Based Medicine). Risk factors associated with the development of VIN include: smoking and coexisting vulvar dermatoses. Risk factors associated with recurrence include: smoking, multifocal disease, and positive surgical margins. Recent studies identified the presence of differentiated VIN/TP53 mutation as the most significant risk factor for both VIN recurrence and malignant progression. CONCLUSIONS: The current body of evidence consists primarily of small retrospective observational studies. Well-designed retrospective case-control series and/or prospective observational studies are urgently needed. Ideally, future studies will collect standardized data regarding associated risk factors and stratify women with VIN based on HPV and TP53 status.

A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses.

BACKGROUND: Many vulvar dermatoses (VDs) are chronic and cannot be "cured," thus affected women must learn to live with the impact of the disease, and its treatment, on their quality of life. AIM: To qualitatively investigate the impact of VDs on women's quality of life through firsthand accounts. METHODS: 12 women, 7 with lichen sclerosus and 5 with erosive vulvovaginal lichen planus recruited from a vulvar disease clinic participated in in-depth, exploratory interviews. Scripts were analyzed by applying a thematic network. The following steps were used: (1) coding the text, (2) development of descriptive themes, and (3) generation of thematic networks. OUTCOMES: The main outcome explored was the narrative experiences of women living with VDs. RESULTS: A global theme of suffering emerged. Themes associated with this suffering were organized under the themes of isolation, interference, and grieving. Women felt isolated because they felt unable to talk about their suffering; experienced a lack of external validation and support; and felt different as individuals, women, and sexual beings. Most women expressed negative views of their genitalia. Women spoke of the VDs, and its management, as interfering with thoughts, activities, and sex life. Symptoms were described as all-encompassing. Women spoke about limiting and/or avoiding daily activities and, in particular, sexual activities. Women described diminished sexual pleasure and experienced loss in their intimate relationships. Women described an ongoing grieving process; anger and sadness over the loss of their former healthy self; the burden of ongoing treatment; and attempts to cope and accept their current condition. CLINICAL IMPLICATIONS: The findings suggest that assessment of women with VDs should include a detailed history of the impact of the VDs on women's psychological and sexual health. STRENGTHS AND LIMITATIONS: A strength of this study is that we openly explored the lived experiences of women who had been clinically diagnosed with vulvar lichen sclerosus and erosive vulvovaginal lichen planus. A limitation is that the findings may not represent the experience of women living with VDs who do not wish to discuss their VDs or who are undiagnosed, untreated, and/or treated by other health-care providers. CONCLUSIONS: Women described profound impact of VDs on psychological and sexual health. Sadownik LA, Koert E, Maher C, et al. A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses. J Sex Med 2020;17:1740-1750.

A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting.

INTRODUCTION: Chronic and distressing genito-pelvic pain associated with vaginal penetration is most frequently due to provoked vestibulodynia (PVD). Cognitive behavioral therapy (CBT) significantly reduces genital pain intensity and improves psychological and sexual well-being. In general chronic pain populations, mindfulness-based approaches may be as effective for improving pain intensity as CBT. AIM: To compare mindfulness-based cognitive therapy (MBCT) with CBT in the treatment of PVD. METHODS: To ensure power of 0.95 to find medium effect size or larger in this longitudinal design, we enrolled 130 participants. Of these, 63 were assigned to CBT (mean age 31.2 years), and 67 to MBCT (mean age 33.7 years). Data from all participants who completed baseline measures were analyzed, with intent-to-treat analyses controlling for years since diagnosis. MAIN OUTCOME MEASURES: Our primary outcome was self-reported pain during vaginal penetration at immediate post-treatment and at 6 months' follow-up. Secondary endpoints included pain ratings with a vulvalgesiometer, pain catastrophizing, pain hypervigilance, pain acceptance, sexual function, and sexual distress. RESULTS: There was a significant interaction between group and time for self-reported pain, such that improvements with MBCT were greater than those with CBT. For all other endpoints, both groups led to similar significant improvements, and benefits were maintained at 6 months. CLINICAL IMPLICATIONS: Mindfulness is a promising approach to improving self-reported pain from vaginal penetration and is as effective as CBT for several psychological endpoints. STRENGTH & LIMITATIONS: A strength of the present study was the robust sample size (n = 130 women) who had received confirmed clinical diagnoses of PVD. CONCLUSION: The present study showed mindfulness to be as effective for most pain- and sexuality-related endpoints in the treatment of PVD. Brotto LA, Bergeron S, Zdaniuk B, et al. A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting. J Sex Med 2019;16:909-923.

Provoked Vestibulodynia in Women with Pelvic Pain.

INTRODUCTION: Pelvic pain and vulvar pain are common conditions in women. In this study, we sought to characterize the clinical picture of patients with concurrent pelvic pain and provoked vestibulodynia (PVD). AIM: To analyze the association between sexual/clinical characteristics and a diagnosis of PVD among women with pelvic pain. METHODS: Cross-sectional analysis of a prospective registry at a tertiary referral center for pelvic pain and endometriosis, involving consecutive non-menopausal sexually active patients 18-49 years-old seen by a single gynecologist from January 2016-December 2017. The sample was divided into 2 groups: pelvic pain with PVD; and pelvic pain alone (without PVD). MAIN OUTCOME MEASURES: Superficial dyspareunia and deep dyspareunia on a 11-point numeric rating scale, and the sexual quality-of-life subscale of the Endometriosis Health Profile-30 (0-100%). RESULTS: There were 129 patients that met study criteria: one third with pelvic pain and PVD (n = 42) and two-thirds with pelvic pain alone (without PVD) (n = 87). Women with pelvic pain and PVD had significantly more severe superficial dyspareunia ≥7/10 (OR = 12.00 (4.48-32.16), P < .001), more severe deep dyspareunia ≥7/10 (OR = 4.08 (1.83-9.10), P = .001), and poorer sexual quality of life (Endometriosis Health Profile-30 ≥50%) (OR = 4.39 (1.67-11.57), P = .002), compared with the group with pelvic pain alone. Women with pelvic pain and PVD also had more anxiety, depression, and catastrophizing, more frequent tenderness of the bladder and pelvic floor, and more common diagnosis of painful bladder syndrome. On the other hand, there were no significant differences between the 2 groups in terms of dysmenorrhea, chronic pelvic pain, abdominal wall allodynia, positive Carnett test for abdominal wall pain, functional quality of life, endometriosis, and irritable bowel syndrome. CONCLUSIONS: In the pelvic pain population, PVD may be associated with more negative impact on dyspareunia, sexual quality of life, and bladder/pelvic floor function, but it may not significantly impact abdominopelvic pain or day-to-day function in general. Bao C, Noga H, Allaire C, et al. Provoked Vestibulodynia in Women with Pelvic Pain. Sex Med 2019;7:227-234.

Multidisciplinary Treatment for Provoked Vestibulodynia: Treatment Trajectories, Predictors, and Moderators of Sexual Distress and Pain.

OBJECTIVES: Multidisciplinary treatment programs for provoked vestibulodynia (PVD) are recommended, yet few have been evaluated. This study examined women's symptom trajectories over time, as well as baseline demographic, psychosocial and pain characteristics as predictors/ moderators of sexual pain and distress following treatment at a clinic using multidisciplinary concurrent methods. We also examined the impact of baseline variables on the probability of having low sexual distress scores following treatment. MATERIALS AND METHODS: Women attending a multidisciplinary treatment program for PVD were invited to complete questionnaires before, following, and at 6 and 18 months after program completion. Questionnaires included the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), State-Trait Anxiety Inventory (STAI), Pain Catastrophizing Scale (PCS), Painful Intercourse Self-Efficacy Scale (PISES), and Pain Vigilance and Awareness Questionnaire (PVAQ). Linear mixed-effects models evaluated the FSDS and FSFI pain subscale as criterion variables, and the other baseline variables as predictors and moderators. RESULTS: Significant improvements in sexual distress and pain were observed over time. No significant moderators were identified, but higher baseline levels of FSFI desire and arousal predicted greater improvements in sexual distress. Similarly, higher baseline levels of desire predicted greater improvements in pain. Among women distressed at baseline and with 6 month FSDS scores, 25% (n=35) were no longer sexually distressed at 6 months; higher baseline levels of desire were associated with greater probability of having low sexual distress at 6 months. DISCUSSION: Although global improvements were observed, women with poorer baseline sexual functioning were less likely to improve after multidisciplinary treatment.

Systematic Review of Treatment Outcome Measures for Vulvodynia.

OBJECTIVES OF THE STUDY: To systematically evaluate the literature regarding vulvodynia treatment outcome measures. METHODS: A systematic literature search on OVID, PubMed, and PsycINFO databases was conducted from inception until May 2016. Studies were included/excluded based on prespecified criteria. Reported outcome measures were organized into 6 core outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT): pain; physical functioning, emotional functioning, participant ratings of global improvement and satisfaction with treatment, symptoms and adverse events, and participant disposition. RESULTS: Of the 206 articles identified for full-text screening, 33 met our criteria. One study adhered to all IMMPACT recommendations. The number of outcomes measured per study ranged from 1 to greater than 20. Patient-reported pain outcomes were found in the majority (27/33; 82%) of studies. Pain severity with intercourse was reported by 24 (73%) of 33 studies-9 different scales were used to measure this outcome. Clinician-reported outcomes were present in 14 (42%) of 33 studies. Methods of measuring vestibular sensitivity by "cotton swab" test were different in 8 of 10 studies. Other domains reported included; physical function (8/33 studies; 24%), sexual function (23/33 studies; 70%), and emotional function (13/33 studies; 39%). Symptoms and adverse events were reported by 15 (45%) of 33 studies. One study formally reported participant disposition using all the information recommended by CONSORT. CONCLUSIONS: Comparison of clinical trial results in vulvodynia is not possible because of a lack of standard treatment outcome measures. Vulvodynia researchers should apply the IMMPACT criteria to guide the development of a minimum core set of standard outcome measures that measure holistic health.

Antenatal Vulvar Pain Management, Labour Management, and Postpartum Care of Women With Vulvodynia: A Survey of Physicians and Midwives.

OBJECTIVE: To examine maternity providers' recommendations for pregnant women with vulvodynia regarding management of vulvar pain and postpartum care, and to examine if, and how, a woman's chronic vulvar pain affects providers' examination and management during labour. METHODS: This research was part of a larger study that invited physicians and midwives to answer a questionnaire regarding pregnancy and childbirth care in women with vulvodynia. To achieve the current objectives, the questionnaire included both dichotomous (yes or no) and open-ended items. The current sample (n = 116) consisted of 75 physicians and 41 midwives. RESULTS: Over 60% of the sample reported making recommendations for vulvar pain management during pregnancy, and 32.8% of providers reported making special postpartum care recommendations for women with vulvodynia. Differences between physicians and midwives were noted for some of these recommendations. For example, to manage vulvar pain, only physicians recommended the use of/change in medications (P <0.001) and only midwives recommended complementary medicines (P = 0.02) and the use of lubricants (P = 0.006) and made recommendations for sexual well-being (P = 0.02). The majority of the sample (75%) reported that a woman having vulvodynia affected labour examination and management; providers most frequently reported minimizing exams and early use of epidural. Over 80% of midwives and 54% of physicians minimized exams during labour for women with vulvodynia (P= 0.01). CONCLUSION: Further research is needed to understand the optimal provision of care for pregnant and postpartum women with vulvodynia. We advocate for increased education of vulvodynia aimed at providers of antenatal, labour, and postnatal care.

The Impact of a Woman's Dyspareunia and Its Treatment on Her Intimate Partner: A Qualitative Analysis.

This study explored the experiences of male partners of women with dyspareunia, secondary to provoked vestibulodynia (PVD), who participated in the Multidisciplinary Vulvodynia Program (MVP). Participants were 16 men between 22 and 45 years of age. Data were collected with semi-structured interviews and analyzed for themes. Men were interviewed about (a) the impact of the woman's PVD on themselves; and (b) the impact of the MVP on themselves. Participants experienced negative psychological effects (e.g., guilt) in addition to activating emotions (e.g., frustration). They reported diminished quantity and quality of sex. In the relationship, PVD caused strain, communication challenges, and possibilities for growth. The benefits, perceived by the partner, of the women participating in the treatment program included improvements in knowledge, communication, and psychological and sexual health.

Clinicians' Perspectives and Experiences Regarding Maternity Care in Women With Vulvodynia.

OBJECTIVE: To assess clinicians' frequency of and comfort with provision of maternity care for women with vulvodynia, their beliefs and practices regarding delivery mode, and frequency of maternal requests for Caesarean section (CS). METHODS: We invited physicians and midwives to complete a questionnaire assessing their frequency of contact with pregnant women with vulvodynia; their level of comfort providing antenatal, intrapartum, and postpartum care for these women; whether they believed that vulvodynia is an indication for elective CS and the frequency of making this recommendation; and the number of patients with vulvodynia who strongly requested CS. RESULTS: Of the 140 participating clinicians, 91 were physicians and 49 were midwives. Most physicians (n = 64; 70.4%) saw patients with vulvodynia at least once per month. Clinicians who saw women with vulvodynia were most likely to see pregnant women with vulvodynia rarely (n = 54; 40.3%) or every six to 12 months (n = 29; 21.6%). Almost one third (n = 44; 31.4%) were not comfortable providing maternity care for these women, and 16.4% (n = 23) agreed that vulvodynia was an indication for elective CS. Of respondents who provided maternity care for women with vulvodynia, 15.4% (n = 18) had recommended CS; the most common reason for doing so was potential worsening of vulvar symptoms. The majority of clinicians who provided maternity care for women with vulvodynia (n = 73; 62.4%) indicated that maternal requests for CS were rare. CONCLUSION: Almost one third of participating clinicians (31.4%) were not comfortable providing maternity care for women with vulvodynia. Despite infrequent maternal requests, a minority of clinicians believed that vulvodynia is an indication for CS and/or made that recommendation. Additional research and education are needed to provide optimal obstetric care for women with vulvodynia.

Provoked Vestibulodynia and the Health Care Implications of Comorbid Pain Conditions.

OBJECTIVE: Sexual pain secondary to provoked vestibulodynia (PVD) is a chronic pain condition affecting up to 16% of women. Women with PVD may report other chronic pain conditions. The goals of this study were (1) to identify the prevalence of self-reported chronic pain conditions in a sample of women with a diagnosis of PVD and seeking treatment, and (2) to compare demographic and clinical characteristics and health care needs of women with PVD alone and women with PVD and two or more self-reported chronic pain conditions. METHODS: We assessed the characteristics of 236 women with PVD alone and 55 women with PVD and comorbid chronic pain using a standardized questionnaire, the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Pain Vigilance and Awareness Questionnaire, and the Female Sexual Distress Scale. RESULTS: Compared with women with PVD alone, women with PVD and other concurrent pain reported a significantly longer duration of pain, pain radiating to other parts of the vulva, and pain interfering in a variety of daily activities. This group was also significantly more likely to have seen more gynaecologists, and to have had more office visits with their gynaecologist than women with PVD alone. They were more likely to have tried anticonvulsants, antidepressants, and stress/relaxation therapy for their PVD and were also more likely to have allergies and skin sensitivities. Finally, this group of women had higher symptoms of depression, trait anxiety, and showed a trend towards more pain vigilance. CONCLUSION: Taken together, these findings suggest that physicians caring for women with PVD and concurrent chronic pain must be alert to the potentially greater health needs among this subsample of women.

Objectif : La douleur sexuelle attribuable à la vestibulodynie provoquée (VDP) est un trouble de douleur chronique qui affecte jusqu'à 16 % des femmes. Les femmes qui présentent une VDP pourraient en venir à signaler d'autres troubles de douleur chronique. Cette étude avait pour objectif (1) d'identifier la prévalence des troubles de douleur chronique auto-signalés au sein d'un échantillon de femmes ayant obtenu un diagnostic de VDP et cherchant à obtenir un traitement; et (2) de comparer les caractéristiques démographiques et cliniques et les besoins en soins de santé des femmes qui ne présentent qu'une VDP et des femmes qui présentent une VDP et au moins deux troubles de douleur chronique auto-signalés. Méthodes : Nous avons évalué les caractéristiques de 236 femmes ne présentant qu'une VDP et de 55 femmes présentant une VDP et une douleur chronique comorbide au moyen d'un questionnaire standardisé, de l'Inventaire de dépression de Beck, du State-Trait Anxiety Inventory, du Pain Vigilance and Awareness Questionnaire et de la Female Sexual Distress Scale. Résultats : Par comparaison avec les femmes qui ne présentaient qu'une VDP, les femmes qui présentaient celle-ci et une autre douleur concomitante ont signalé une douleur d'une durée significativement prolongée, une douleur irradiant vers d'autres parties de la vulve et une douleur nuisant à diverses activités de la vie quotidienne. Les femmes de ce groupe étaient également significativement plus susceptibles que les femmes ne présentant qu'une VDP d'avoir consulté un plus grand nombre de gynécologues et de s'être rendues un plus grand nombre de fois au cabinet de leur gynécologue. Elles étaient plus susceptibles d'avoir fait l'essai d'anticonvulsivants, d'antidépresseurs et d'une thérapie anti-stress / de relaxation pour contrer leur VDP, et également plus susceptibles de connaître des allergies et des sensibilités cutanées. Enfin, les femmes de ce groupe présentaient des symptômes accrus de dépression, une anxiété réactionnelle et une tendance envers une vigilance accrue en ce qui concerne la douleur. Conclusion : Considérées dans leur ensemble, ces constatations semblent indiquer que les médecins qui offrent des soins à des femmes qui présentent une VDP et une douleur chronique concomitante doivent être sensibles aux besoins de santé potentiellement accrus au sein de ce sous-groupe de femmes.

Impact of a multidisciplinary vulvodynia program on sexual functioning and dyspareunia.

INTRODUCTION: For many years, multidisciplinary approaches, which integrate psychological, physical, and medical treatments, have been shown to be effective for the treatment of chronic pain. To date, there has been anecdotal support, but little empirical data, to justify the application of this multidisciplinary approach toward the treatment of chronic sexual pain secondary to provoked vestibulodynia (PVD). AIM: This study aimed to evaluate a 10-week hospital-based treatment (multidisciplinary vulvodynia program [MVP]) integrating psychological skills training, pelvic floor physiotherapy, and medical management on the primary outcomes of dyspareunia and sexual functioning, including distress. METHOD: A total of 132 women with a diagnosis of PVD provided baseline data and agreed to participate in the MVP. Of this group, n = 116 (mean age 28.4 years, standard deviation 7.1) provided complete data at the post-MVP assessment, and 84 women had complete data through to the 3- to 4-month follow-up period. RESULTS: There were high levels of avoidance of intimacy (38.1%) and activities that elicited sexual arousal (40.7%), with many women (50.4%) choosing to focus on their partner's sexual arousal and satisfaction at baseline. With treatment, over half the sample (53.8%) reported significant improvements in dyspareunia. Following the MVP, there were strong significant effects for the reduction in dyspareunia (P = 0.001) and sex-related distress (P < 0.001), and improvements in sexual arousal (P < 0.001) and overall sexual functioning (P = 0.001). More modest but still statistically significant were improvements in sexual desire, lubrication, orgasmic function, and sexual satisfaction. All improvements were retained at 2- to 3-month follow-up. CONCLUSION: This study provides strong support for the efficacy of a multidisciplinary approach (psychological, pelvic floor physiotherapy, and medical management) for improving dyspareunia and all domains of sexual functioning among women with PVD. The study also highlights the benefits of incorporating sexual health education into general pain management strategies for this population.

Etiology, diagnosis, and clinical management of vulvodynia.

Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.

A comparison of demographic and psychosexual characteristics of women with primary versus secondary provoked vestibulodynia.

OBJECTIVES: Provoked vestibulodynia (PVD) is a distressing genital pain condition affecting approximately 12% of premenopausal women. It has been speculated that primary (ie, lifelong) and secondary (ie, acquired) PVD may represent 2 distinct conditions with different etiologies. There is also evidence that primary and secondary PVD subtypes may respond differently to conventional treatments. The goal of this study was to compare the demographic, clinical, and psychosexual characteristics of a large sample of premenopausal women with primary and secondary PVD. METHODS: A total of 132 premenopausal women (n=42 primary; n=90 secondary) with PVD who sought treatment in a Multidisciplinary Vulvodynia Program completed demographic questions and a battery of validated self-report measures before treatment. RESULTS: Women with primary PVD had a longer duration of PVD as well as more time before diagnosis. Women with secondary PVD reported significantly more clitoral hood pain, higher overall vestibular pain levels, more overall sexual dysfunction and sex-related distress, and proportionately more intercourse occasions that were painful. Women with primary pain stated they had significantly more dysmenorrhea and were more likely to report that their partners were unaware of their PVD symptoms. There were no significant subtype differences on any psychological measure but a trend towards higher magnification of symptoms in women with secondary PVD. DISCUSSION: Overall the findings suggest some important differences in the characteristics of women with primary versus secondary PVD which may have management-related implications.

Provoked vestibulodynia-women's experience of participating in a multidisciplinary vulvodynia program.

INTRODUCTION: Provoked Vestibulodynia (PVD) is the most common cause of pain with intercourse that affects reproductively aged women. The treatment outcome literature suggests that existing treatments, when administered individually, may have only limited benefits for improving pain, and that multidisciplinary approaches may be more effective for reducing pain and pain-associated distress. A program that offers education, group cognitive behavioral therapy, pelvic floor physiotherapy, and medical appointments was developed and implemented at our hospital site. AIM: To explore the experiences of women who participated in the Multidisciplinary Vulvodynia Program (MVP) in order to identify the perceived benefits of this program. METHODS: Qualitative retrospective study. A semi-structured interview format was used to interview graduates of the MVP. Nineteen women, mean age 30.8 (20-54 years), participated in a one-on-one in-depth interview with a trained interviewer. The key question asked was "What has been the impact of the mvp on your life?" interviews were audio-recorded, transcribed, and qualitatively analyzed for major themes. MAIN OUTCOME MEASURE: Content analysis of interview transcripts. RESULTS: Five main themes emerged and included: increased knowledge, gained tools/skills, perceived improved mood/psychological well-being, a sense of validation and support, and an enhanced sense of empowerment. CONCLUSION: Overall, a multidisciplinary vulvodynia program was perceived as being beneficial for women with PVD.

Post-surgical treatment of melanoma in situ of the vulva with imiquimod.

BACKGROUND: Melanoma in situ is a rare malignant lesion of the vulva. The standard treatment is surgical excision. CASE: We describe a case of melanoma in situ of the vulva in a 72-year-old woman that reoccurred after surgical excision and was treated successfully with topical 5% imiquimod. CONCLUSION: There may be a role for imiquimod in treating melanoma in situ of the vulva.