Validation of a clinical tool for vestibular trophism in postmenopausal women.

OBJECTIVE: This study aimed to develop and validate a clinical tool to assess vestibular trophism in women with genitourinary syndrome of menopause (GSM). METHODS: In this cross-sectional study, the principal investigator's center and three external reviewers assessed the vestibular images of postmenopausal women using a multi-item tool defined as vestibular trophic health (VeTH), which assessed five criteria: petechiae, pallor, thinning, dryness and redness. Dryness, dyspareunia, vulvar pain and the Vaginal Health Index (VHI) were also evaluated. RESULTS: Analysis of the intraclass correlation coefficient (0.76; confidence interval 0.62-0.82) and Cronbach's alpha coefficient (0.78; confidence interval 0.64) indicated an inter-rater reliability and reproducibility of VeTH in the 70 women enrolled in the study. The observed covariance between a high VeTH score and the symptom severity demonstrated a significant correlation, which was not evident between VeTH and the total VHI score. CONCLUSIONS: The vulvar vestibule is the main location of genital tenderness, primarily responsible for burning/pain and entry dyspareunia because of its capacity to develop an excess of nociceptors upon sexual hormone deprivation. Our study indicated that VeTH can be a reproducible tool for the morphological classification of vestibular trophism and bears a significant correlation with the severity of the symptoms.

Vaginal biological and sexual health--the unmet needs.

The vagina is a most neglected organ. It is usually clinically considered with a minimalistic view, as a 'connecting tube' for a number of physiologic functions: passage of menstrual blood, intercourse, natural conception and delivery. Unmet needs include, but are not limited to, respect of vaginal physiologic biofilms; diagnosis and care of the optimal tone of the levator ani, which surrounds and partly support it; care of its anatomic integrity at and after delivery and at pelvic/vaginal surgery; care of long-term consequences of pelvic radiotherapy; long-term care of the atrophic changes it will undergo after the menopause, unless appropriate, at least local, estrogen therapy is used; appreciation and respect of its erotic meaning, as a loving, receptive, 'bonding' organ for the couple. The vaginal erotic value is key as a non-visible powerful center of femininity and sexuality, deeply and secretly attractive in terms of taste, scent (together with the vulva), touch and proprioception. The most welcoming when lubrication, softness and vaginal orgasm award the woman and the partner with the best of pleasures. Prevention of sexual/vaginal abuse is a very neglected unmet need, as well. Who cares?

A proof of concept that experience-based management of endometriosis can complement evidence-based guidelines.

Background: Management of endometriosis should be based on the best available evidence. The pyramid of evidence reflects unbiased observations analysed with traditional statistics. Evidence-based medicine (EBM) is the clinical interpretation of these data by experts. Unfortunately, traditional statistical inference can refute but cannot confirm a hypothesis and clinical experience is considered a personal opinion. Objectives: A proof of concept to document clinical experience by considering each diagnosis and treatment as an experiment with an outcome, which is used to update subsequent management. Materials and Methods: Experience and knowledge-based questions were answered on a 0 to 10 visual analogue scale (VAS) by surgery-oriented clinicians with experience of > 50 surgeries for endometriosis. Results: The answers reflect the collective clinical experience of managing >10.000 women with endometriosis. Experience-based management was overall comparable as approved by >75% of answers rated ≥ 8/10 VAS. Knowledge-based management was more variable, reflecting debated issues and differences between experts and non-experts. Conclusions: The collective experience-based management of those with endometriosis is similar for surgery-oriented clinicians. Results do not conflict with EBM and are a Bayesian prior, to be confirmed, refuted or updated by further observations. What is new?: Collective experience-based management can be measured and is more than a personal opinion. This might extend EBM trial results to the entire population and add data difficult to obtain in RCTs, such as many aspects of surgery.

[Short-course treatment of vulvovaginal candidiasis: comparative study of fluconazole and intra-vaginal fenticonazole]. / Il trattamento "short course" della candidosi vulvovaginale acuta: studio comparativo tra il fluconazolo ed il fenticonazolo intravaginale.

AIM: The aim of this paper was to compare the efficacy of fluconazole 150 mg and intra-vaginal fenticonazole 600mg in short-course treatment of the acute episode of vulvovaginal candidiasis (VVC). METHODS: In a prospective study, 80 patients with clinical and mycological (SavvyCheck™ test) confirmed VVC were enrolled and divided randomly in two groups. Forty patients received oral fluconazole (150 mg), whereas 40 patients received intra-vaginal tablet fenticonazole (600 mg). Two sequential doses of azole agents were given 3 days apart (short-course treatment). Second and third visits were done for all patients seven and 30±5 days after treatment. RESULTS: At the second visit, 31 patients (77.5%) were cured clinically (Sobel score <4) in fluconazole group and 32 patients (80%) in fenticonazole group (P=0.876). The vulvovaginal pruritus was reduced in lower time in fenticonazole patients than in fluconazole group (mean 2.3 days versus 4.5 days, P=0.047). At the third visit, three patients in fluconazole group and two patients in fenticonazole group had clinical sign of VVC. CONCLUSION: Fluconazole and intravaginal fenticonazole are both effective to cure symptoms of VVC but fenticonazole appears to reduce the pruritus in less time.

Correlates of sexual functioning in Italian menopausal women.

OBJECTIVES: To analyze the sexuality of Italian menopausal women. DESIGN: Cross-sectional study. POPULATION: Menopausal women consecutively observed during the study period in menopause clinics. METHODS: Women were interviewed about their current and premenopausal sexual activity: sexual intercourse frequency and self-rated sexual desire, capacity for orgasm and sexual satisfaction were recorded. Women were defined as having poor sexual functioning if they had one or less sexual intercourses per week or answered 'absent/poor' to the questions about the sexual domains. RESULTS: Oral hormone therapy (HT) use (odds ratio (OR) 0.43 for desire, 0.54 for orgasm and 0.56 for overall sexual satisfaction, all p < 0.001) and transdermal HT (OR 0.38, 0.53 and 0.53, respectively, all p < 0.001) were significantly associated with lower risk of poor sexual functioning. Higher physical and mental component scores (PCS and MCS, range 0-100) of the Short Form-12 are inversely related to poor sexual functioning (OR by point 0.96, 0.95, 0.95 for PCS and 0.96, 0.96 and 0.95, for MCS, respectively, all p < 0.001). Pain during and symptoms after sexual intercourse were significantly related to desire (OR 1.96 and 1.78, respectively), orgasm (OR 2.22 and 2.06, respectively) and sexual satisfaction (OR 2.02 and 1.79, respectively). The partner's health problems were associated with low sexual intercourse frequency (OR 4.18, p < 0.001) and absent/poor overall satisfaction (OR 2.61, p < 0.001). CONCLUSIONS: This study shows that, in menopausal Italian women attending menopause clinics, sexual function is associated with the quality of sexual life in reproductive age, partner's health status, current quality of life, HT and occurrence of pain during and symptoms after sexual intercourse.

Therapeutic options for postmenopausal female sexual dysfunction.

BACKGROUND: Female sexual dysfunction (FSD) is a multidimensional problem combining biological, psychological and interpersonal elements of multiple etiologies. Menopause-related sexual dysfunction may not be reversible without therapy. Hormonal deficiency does not usually decrease in severity over time. Many options are available for the successful treatment of postmenopausal FSD. OBJECTIVE: To review the pharmacological and non-pharmacological therapies available for postmenopausal FSD, focusing on practical recommendations for managing postmenopausal women with sexual complaints, through a literature review of the most relevant publications in this field. PSYCHOSOCIAL THERAPY: This type of therapy (basic counselling, physiotherapy and psychosexual intervention) is considered an adaptable step-by-step approach for diagnostic and therapeutic strategies, normally combined with biomedical interventions to provide optimal outcomes. PHARMACOLOGICAL THERAPY: For postmenopausal FSD, many interventional options are now available, including hormonal therapies such as estrogens, testosterone, combined estrogen/testosterone, tibolone and dehydroepiandrosterone. CONCLUSIONS: Menopause and its transition represent significant risk factors for the development of sexual dysfunction. FSD impacts greatly on a patient's quality of life. Consequently, it is receiving more attention thanks to the development of effective treatments. Non-pharmacological approaches should be used first, focusing on lifestyle and psychosexual therapy. If required, proven effective hormonal and non-hormonal therapeutic options are available.

[Menstruation, inflammation and comorbidities: implications for woman health]. / Mestruazione, inflammazione e comorbilità: implicazioni per la salute della donna.

Menstruation is the genital sign of systemic endocrine events. Heterogeneity of perimenstrual symptoms is associated with levels of inflammation, triggered by the fall of estrogens at genital and systemic level. Aim of the review is to concisely analyze the evidence on: 1) genital and systemic endocrine and inflammatory events associated with periods and perimenstrual symptoms; 2) rationale of intervention to reduce their intensity and impact on women's lives. This review of the literature, selected with a clinical perspective, supports the inflammatory basis of the menstrual event, triggered by the estrogens' and progesterone' fall. Moreover, the review analyzes the endocrine and inflammatory basis of perimenstrual pelvic and extrapelvic symptoms such as: menstrual pain, menstrual irregularities, premenstrual syndrome, gastrointestinal symptoms, catamenial headache, depression, perimenstrual myalgia, joint pain, allergies and asthma, heavy menstrual bleeding, associated ironless anemia, brain and behavioral consequences. Inflammation, with increase of cytokines and other markers, is modulated by the degranulation of mast cells at the basal level of the endometrium, in the blood, in all the organs where mast-cell are already activated from local pathologies and within the brain. The shift of inflammation from physiological to a pathologic intensity increases the severity of perimenstrual symptoms. Symptoms persist, moderately attenuated, also during the hormone free interval (HFI) in contraception. The HFI reduction from seven to two days significantly reduces menstrual inflammation and associated symptoms.

AMS 700 CX inflatable penile implants for Peyronie's disease: functional results, morbidity and patient-partner satisfaction.

This study was designed to clarify the functional results, morbidity and the patient-partner satisfaction observed with, the American Medical System 700 CX three-piece inflatable prosthesis in the treatment of impotence associated with Peyronie's disease. Thirty-three patients were treated and additional plaque surgery was performed in 13 cases (40%). Within 10 days of surgery, four patients (12%) developed a wound infection which was treated conservatively and one patient (3%) experienced glandular ischemia. At the 6-week follow-up, complete penile straightening was achieved in 23 patients (70%), while penile rigidity was considered optimal by all patients. On the contrary, the penis was considered short by 10 patients (30%). Five diabetic patients (15%) complained of severe scrotal and penile pain during full activation of the implant and in one of these patients (3%) the implant had to be removed. Due to spontaneous erections occurring after implant activation one patient (3%) required replacement of the reservoir from the Retzius space into the peritoneum. At the long-term follow-up (mean +/- SE: 17 +/- 2.2 months), 23 patients were evaluated and all found to be engaging in intercourse with the prosthesis. However, five patients (21%) and three of the 13 partners (25%) assessed were not yet completely satisfied. The American Medical System CX700 inflatable penile prosthesis obtains complete penile straightening in 70% and rigidity in 100% of impotent patients with Peyronie's disease. Patients should be fully informed about possible surgical morbidity and actual post-operative penile length.

The biological basis of female sexuality.

Human sexuality has three main roots: biological, motivational-affective-relational, and cognitive. Unfortunately, in women, the biological dimension is usually disregarded. Hormones are necessary, but not sufficient, factors to maintain a satisfying human libido. In women, oestrogens prime the central nervous system, acting as neurotrophic and psychotrophic factors throughout life. They also prime the sensory organs, including the skin with its sebaceous and sweat glands, which are the key receptors for external sexual stimuli. Oestrogens are also the 'permitting factors' for the action of vaso-intestinal peptide, the key neurotransmitter involved in the endothelial and vascular changes leading to vaginal lubrication. Other factors, such as medication, alcohol and other health problems, can modify the biological impact of hormones on libido. Depression may cause a progressive decline in interest in sexual behaviour leading to low libido, difficulty in sexual arousal, secondary anorgasmia and/or frank sexual aversion. Increasing attention of doctors towards the sexual problems of women will dramatically improve female quality of life, especially during difficult periods of transition.

Libido: the biologic scenario.

Libido is a comprehensive and yet elusive word that indicates basic human mental states--and their biological counterparts--involved in the beginning of sexual behavior. It has three main roots: biological, motivational-affective and cognitive. All these dimensions may be variably affected in the post menopause, contributing to a progressive decrease of sexual drive that parallels the process of aging. Loss of estrogens and, specifically, of androgens deprives female libido of major biological fuel. The effect of this loss is pervading, affecting the central nervous system, the sensory organs that are the major windows to environmental sexual stimuli and the quality of sexual response, central, peripheral non-genital and genital. Prolactin increase may further inhibit libido. Arousal disorders, dyspareunia, orgasmic difficulties, dissatisfaction, both physical and emotional, may contribute to a secondary loss of libido. Depression, anxiety and chronic stress, may interfere with central and peripheral pathways of the sexual response, reducing the quality of sexual function mostly in its motivational root. Relational conflicts and/or marital delusions and partner-specific problems, erectile deficit first, may contribute to the fading of sexual drive in the post-menopausal years. Well tailored HRT, including androgens in selected cases, may reduce the biological causes of loss of libido. A comprehensive treatment requires a balanced evaluation between biological and psychodynamic factors.

Strategies for effectively addressing women's concerns about the menopause and HRT.

HRT has many benefits for postmenopausal women yet acceptance and compliance with therapy is low. This paper sets out some of the main concerns women have regarding HRT and highlights ways that physicians can effectively deal with these concerns. Physicians dealing with women concerned about starting or continuing HRT should conduct patient-centered consultations employing good counseling skills. Dealing effectively with women's concerns means addressing their attitude to HRT, listening to the patients' fears in an understanding and non-dismissive way, and focusing on good communication. Common concerns relating to unwanted effects such as bleeding, fear of cancer, weight gain, thrombosis, general systemic effects, and the use of medical intervention generally, can be dealt with if the physician follows the principles for conducting a patient-centered interview. When it comes to decisions about starting and continuing on HRT, it is important that women are treated with understanding, their concerns are taken seriously, and they are given time to air their views and ask questions. Tailoring treatments to individual patients can overcome many of the problems women have with HRT, however it is important that the decision to start HRT, and the most suitable regimen and delivery system to use, be decided in partnership with the patient. This should result in the patient having a better understanding of HRT, and may improve compliance.

Cardioprotective effects of ovarian hormones and the HERS in perspective.

The increased population of women in menopause living in the industrialized countries is associated with an increase of diseases which are dependent or facilitated by a state of estrogen deficiency such as cardiovascular and cerebrovascular diseases. Several studies have shown that estrogen replacement therapy reduces the occurrence of coronary and may be of cerebrovascular disease by nearly 50% in treated women compared to non-users. These findings are supported by the evidence that estrogens have a beneficial effect on cholesterol metabolism and deposition, contributing to the inhibition of atherosclerotic plaque formation in arterial walls as well as a direct effect on the vessel wall. Progestins may, in some cases, counteract the beneficial effect of estrogens upon cardiovascular functions. More androgenic progestins may have a detrimental effect upon vascular reactivity while less androgenic progestins seem not to reduce the beneficial effect of estrogens. Of interest, continuous combined administration of hormone replacement therapy seem to be preferable for women with coronary artery disease or for those with increased cardiovascular risk. Case-control and cohort studies have shown that estrogen progestin therapy is associated with a significant reduction of cardiovascular mortality and morbidity. The HERS study has added critical data regarding the cardioprotective effect of hormone replacement therapy in elderly women with proven coronary artery disease. Because of the several methodological and statistical flaws of the HERS study, further studies are warranted to evaluate the effect of hormone replacement therapy on cardiovascular prognosis. Large scale randomized studies will evaluate the effect of estrogen and estrogen-progestin replacement therapy upon cardiovascular events in menopausal women. Until completion of these studies hormone replacement therapy in women with increased cardiovascular risk should be seen with no enthusiasm but also with no fear.

Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision.

In light of various shortcomings of the traditional nosology of women's sexual disorders for both clinical practice and research, an international multi-disciplinary group has reviewed the evidence for traditional assumptions about women's sexual response. It is apparent that fullfilment of sexual desire is an uncommon reason/incentive for sexual activity for many women and, in fact, sexual desire is frequently experienced only after sexual stimuli have elicited subjective sexual arousal. The latter is often poorly correlated with genital vasocongestion. Complaints of lack of subjective arousal despite apparently normal genital vasocongestion are common. Based on the review of existing evidence-based research, many modifications to the definitions of women's sexual dysfunctions are recommended. There is a new definition of sexual interest/desire disorder, sexual arousal disorders are separated into genital and subjective subtypes and the recently recognized condition of persistent sexual arousal is included. The definition of dyspareunia reflects the possibility of the pain precluding intercourse. The anticipation and fear of pain characteristic of vaginismus is noted while the assumed muscular spasm is omitted given the lack of evidence. Finally, a recommendation is made that all diagnoses be accompanied by descriptors relating to associated contextual factors and to the degree of distress.

HRT: the woman's perspective.

Questionnaire studies in Europe show that women's concerns at the menopause are more related to their self-image and sexual identity than to medical consequences such as osteoporosis or coronary heart disease. Women long for help with menopausal problems, yet are concerned about the potential side effects of HRT and often perceive the information they receive from their doctors to be inadequate. Adverse effects of menopausal estrogen deprivation on sexual and psychological function occur via two main mechanisms. Firstly, the physical changes that occur at the menopause affect body image, sexual function and women's relationships with their partners. Lack of estrogens worsens the effects of ageing on the female body and psyche. Secondly, there are changes in neuroendocrine and psychological function (e.g. effects on mood, memory and sleep patterns), affecting ego and self-perception. Estrogen replacement in hormone replacement therapy (HRT) improves both sexual and psychological self-image and function.

Proposal of diagnostic approach in mammary pathology.

The Authors, on the basis of the literature and their own experience, propose a diagnostic schedule for detection of breast disease based on integrated thermography, diaphanoscopy, echography and mammography.

Hormones and risk of breast cancer.

PIP: This paper reports the results of a study of 50 menopausal women receiving hormonal replacement therapy. The majority (29) had surgical menopause; their mean age was 45.7 years. It was hypothesized that progestins could equilibrate the effects of the estrogenic stimulation on the mammary and endometrial target tissues of women on hormonal replacement therapy. The treatment schedule consisted of conjugated estrogens (Premarin) 1.25 mg/day for 21 days and Medroxyprogesterone acetate 10 mg/day for 10 days in each month. The mean treatment period was 18 months. During the follow-up period, attention was paid to breast modifications as evidenced by symptomatology, physical examination, and plate thermography. Mastodynia was reported by 21 patients, and physical examination revealed a light increase in breast firmness in 12 women and a moderate increase in breast nodularity in 2 women. Themography confirmed the existence of an excessive breast stimulation in 1 women who complained of moderate mastodynia and in 5 of the 7 women who complained of severe mastodynia. Normalization was obtained by halving the estrogen dose. These results suggest that hormonal replacement therapy can be safely prescribed if the following criteria are satisfied: 1) preliminary evaluation of patients from a clinical, metabolic, cytologic, and mammographic perspective; 2) cyclic treatment schedule, with a progestative phase of 10 days; and 3) periodic complete follow-up, with accurate thermographic evaluation of the breast target tissues.^ieng

Oral contraceptives and breast disease.

PIP: The influence of oral contraceptives (OCs) on breast disease can vary according to their pharmacologic content and interaction with the patient's endocrine habits. Data on this topic are taken from: 1) histologic examinations on patients undergoing contraceptive treatment, 2) studies on experimental toxicity in animals, and 3) epidemiologic examinations. The tests have thus far failed to prove that the administration of OCs causes breast cancer or influences the experimental carcinogenesis in primates or sub-primates. Many epidemiologic studies have even shown a decreased risk of mastopathy in contraceptive users. Not only the doses and hormonal content but also the duration of administration, and any simultaneous or subsequent estrogen administration must be considered when evaluating risk. Combinations of OCs with estrogen predominance must be avoided in patients affected by mastosis.^ieng

Non mutilant radical vulvectomy vs radical vulvectomy.

20 women, matched for age, site of primary tumor, histotype and stage, have been selected among patients affected with vulvar carcinoma for a study comparing classic radical vulvectomy vs "non mutilant" radical surgery. Detailed results actually available are discussed, showing that "non mutilant" technique gives results comparable to classic radical vulvectomy in terms of survival and recurrence rate; with minor functional and aesthetic damage, minor side effects and shorter post operative course.

[Antineoplastic agents and pregnancy]. / Antineoplastici e gravidanza.

The current impossibility of establishing a definite causal relationship between the administration of antineoplastic drugs before and/or during pregnancy and possible modifications of the gestational attitude in the treated women is discussed after a review of the Literature. The data till now reported are often deficient as far as concerns the evaluation of either the fetal, perinatal and post-natal parameters and the past and current reproductive performance of the patients on study. The need for strict methodology in the study and report of feto-maternal parameters to provide a comprehensive answer to the questions raised by the use of antineoplastic drugs before and/or during pregnancy is discussed in detail.

Epidemiology of nipple discharge.

The Authors report their personal observations of nipple discharge in gynecologic patients admitted to the Obstetric and Gynecologic Department of Padua University or applying to the Senologic Diagnostic- or Endocrinology-Departments of the same. After dividing breast secretions into two groups - the neuroendocrine and the strictly mammary ones - the Authors discuss their etiopathogenesis, incidence, and clinical significance (mainly as to their possible association to breast malignancies), and present their personal results. At the end, a careful examination of all nipple discharges is recommended, which should include, besides cytological evaluation, a complete assessment of the neuroendocrine function and a watchful investigation of local breast conditions.