Vulvar vestibulitis: physical or psychosexual problem?

Objective: To examine whether vestibulitis has a physical or a psychosexual etiology.Data Sources: MEDLINE was searched to retrieve publications dating from January 1981 through June 1998 that evaluated the outcomes of surgical treatment and the psychosexual theory of the origin of vestibulitis.Integration: Articles were analyzed for methods of subject selection and surgery, surgical outcome, and length of follow-up.Results: A significant decrease in symptoms (complete responses + partial responses) was reported by 89% of 646 women who had perineoplasty for vulvar vestibulitis. Complete resolution of dyspareunia with surgical treatment was reported in 72% of 512 women whose cases were reviewed in studies in which complete responses and partial responses were evaluated separately. Women with vestibulitis did not differ from the normal population with respect to marital satisfaction, psychologic distress, or psychopathology. A suggestion that childhood sexual abuse caused vestibulitis has not been confirmed. The findings of somatization and shyness might be explained as results rather than causes of vulvar vestibulitis.Conclusion: We do not agree that vestibulitis is a psychosexual problem and one that should not be treated surgically. A high rate of success can be achieved with proper surgical treatment.     

Endometriosis--is it treatable?

Its etiology remains uncertain, its pathogenesis disputed and its treatment poor. Most medical treatment is based on ovulation suppression and inducing amenorrhoea. New findings on the genetics, the possible roles of the environment and the immune system, intrinsic abnormalities in the endometrium and secreted products of endometriotic lesions have given explanation into the pathogenesis of this disorder and give us new trends for treatment the disease.     

Vulvar vestibulitis syndrome: an important factor in the evaluation of lifelong vaginismus?

The aim of the study was to investigate the prevalence of vulvar vestibulitis syndrome (VVS) in a sample of women suffering from lifelong vaginismus (N=91). Lifelong vaginismus is defined as "having a history of never having been able to experience penile entry of the vagina". The results with respect to VVS are compared with the results of women who are suffering from pain during intercourse (superficial dyspareunia) (N=84). Both patients groups were recruited from two treatment outcome studies. Using a standard physical examination, erythema was found in 77%, pain "on touch" in 69% and erythema and pain on the same location was seen in 56% of the patients with lifelong vaginismus. Furthermore, it was found that erythema (94%), pain (98%) and erythema and pain on the same location (92%) were more frequently found in patients with dyspareunia compared to women with lifelong vaginismus. It is concluded that pain is an integral part of the experiences in the majority of women with lifelong vaginismus.     

Azathioprine and breastfeeding: is it safe?

Traditionally, women receiving azathioprine have been discouraged from breastfeeding because of theoretical potential risks of neonatal bone marrow suppression, susceptibility to infection, and pancreatitis. The aims of this study were to measure the concentration of 6-mercaptopurine (6-MP) in breast milk of mothers receiving azathioprine and in the blood of their babies and to investigate any immunosuppressive effects on the babies. Women receiving azathioprine, who after appropriate counselling wished to breastfeed their babies, were approached for inclusion in the study. Breast milk samples were obtained from recruited women, and 6-MP levels were measured in each breast milk sample. Haemoglobin level, white cell and platelet counts, and 6-MP and 6-thioguanine nucleotides (6-TGN) levels were measured in the respective neonatal blood samples. Clinical signs of immunosuppression in the neonates were noted. Thirty-one breast milk samples were collected from ten women. Low concentrations of 6-MP (1.2 and 7.6 nanograms/ml, compared with therapeutic immunosuppressant level of 50 nanograms/ml in serum) were detected in two breast milk samples obtained from one woman. 6-MP was not detected in any of the other 29 samples. 6-MP and 6-TGN were undetectable in the neonatal blood. There were no clinical or haematological signs of immunosuppression in any of the ten neonates. We conclude that breastfeeding should not be withheld in infants of mothers receiving azathioprine.     

Borderline form of empty follicle syndrome: is it really an entity?

We report two patients who were administered erroneously 1000 IU HCG instead of 10,000 IU for ovulation triggering in an assisted reproductive technology (ART) cycle. In one case no oocyte was retrieved from eight mature follicles after several washing attempts and retrieval day serum beta-HCG level was 21 mIU/ml. As there was no follicle in the other ovary we did not try a rescue protocol. In the other case two immature and one mature oocytes were retrieved from 15 mature follicles located in both ovaries. Retrieval day serum beta-HCG level was 12 mIU/ml. ICSI was performed in one mature and two in vitro maturated oocytes and the embryo transfer that was done 72 h after the retrieval yielded a healthy singleton pregnancy. Our experience shows that a borderline form of EFS may be an entity and it may be possible to see the formation of periovulatory events and even to obtain a pregnancy in an ART cycle where the ovulation was triggered by 1000 IU HCG.     

Mild postnatal anemia: is it a problem?

Mild postnatal anemia is common. However, determination of postnatal hemoglobin level or iron supplementation are not routine in many obstetric units. This study was designed to evaluate the impact of mild postnatal anemia and iron supplementation on women. One hundred fifty women who had postnatal hemoglobin levels between 80 and 99 g/L were randomly assigned into two groups with iron tablets or placebo provided from the time of diagnosis until reassessment at 6 weeks. The patients' general well-being, hemoglobin levels, iron status, side effects, and compliance were assessed. One hundred twenty-two women returned for reassessment. Twelve (9.8%) of the 122 women recruited and four (3.2%) of 122 nonanemic matched controls complained of dizziness 2 days after delivery; the difference was statistically significant (chi2 test, p<0.05). At 6 weeks postpartum, significantly more women were anemic (chi2 test, p<0.05) and iron deficient (chi2 test, p<0.01) in the placebo group. The score of general well-being as assessed by a 4-point scale was significantly higher in the iron supplementation group (Mann-Whitney test, p<0.05). The amounts of drugs consumed in both groups were comparable and the incidences of side effects were similar.     

Tying a loop-to-strand suture: is it safe?

OBJECTIVE: This study was undertaken to evaluate the integrity of the loop-to-strand knot when tied with square and nonidentical sliding knots. STUDY DESIGN: The synthetic absorbable monofilament suture poliglecaprone 25 in 0 and 2-0 suture gauges was used in this experiment. For each suture gauge, 3 groups of knots were tested: (1) single strand-to-single strand, flat square knot, (2) loop-to-single strand, flat square knot, and (3) loop-to-single strand, nonidentical sliding knot. All knots were tied with 6 throws. The proportion of knots becoming untied was compared among the 3 groups for each suture gauge. Ultimate load required to untie or break knots within each group was also evaluated. RESULTS: The loop-to-strand knot performed well in both suture gauges tested as long as it was tied with a flat square knot. The loop-to-strand knot tied with a nonidentical sliding knot had an unacceptably high failure rate. CONCLUSION: The loop-to-strand termination of a continuous suture may be acceptable when tied with a 6-throw flat square knot but not acceptable if tied with sliding knots.     

Patient-friendly IVF: how should it be defined?

"Patient-friendly" IVF must be associated with a healthy newborn achieved in a safe, cost-effective, and timely manner. Patients are best served when physicians provide honest appraisal of treatment techniques and outcomes using the evidence available from scientific study.     

Vulval vestibulitis: a common cause of dyspareunia?

The prevalence of vulval vestibulitis was evaluated in a prospective observational study. Four hundred women from West Hertfordshire, 100 each from community family planning, antenatal, general practice and genitourinary clinics were investigated. Participants completed a questionnaire and were examined for vulval erythema and point tenderness. An algesiometer was also used to evaluate tenderness. The prevalence of vestibulitis varied from 2.9% to 9.8% depending on the stringency of diagnostic criteria and the method of ascertaining pain. Vulval vestibulitis cannot be accurately defined by current criteria, but superficial dyspareunia appears to be a frequent problem in the community in women consulting for unrelated matters.     

Vulvar disease: a pelvic floor pain disorder?

OBJECTIVE: The purpose of this study was to compare the rates of painful bladder syndrome and functional bowel disorders in women with vulvar disease and control subjects. STUDY DESIGN: In this cross-sectional survey, a questionnaire that contained validated outcome measures was administered to women who were seeking care in a vulvar disease clinic and in general gynecology clinics. RESULTS: Women who were seen at a vulvar disease clinic were 2.18 (95% CI, 1.19, 3.97) times more likely to have painful bladder syndrome and 2.13 (95% CI, 1.35, 3.35) times more likely to have functional bowel disorders than general gynecology clinic control subjects after multivariable analyses. CONCLUSION: Painful bladder syndrome and functional bowel disorders are more prevalent in women who are seen at a vulvar disease clinic than gynecology clinics control subjects. These associations may reflect a common origin for these disorders in certain women. These findings lay the groundwork for future research to investigate a potential "pelvic floor pain disorder," which is a disease entity that would combine the diagnostic criteria for vulvar, bladder, and bowel pain disorders.     

Stillbirth: is it preventable?

In the UK stillbirth, describes the death of a baby before birth after 24 completed weeks of pregnancy. The rate has decreased in the UK over recent years but at a slower pace than other similar high-income countries. The association of certain risk factors (including maternal age, previous poor obstetric outcome, smoking and obesity) is clearly documented, though only a number of these factors can be modified. Use of interventions including the ‘Saving Babies Lives’ Care Bundle focussing on smoking cessation, assessment for small for gestational age (SGA) babies, educating women regarding reduced fetal movements and effective fetal monitoring during labour aim to reduce both antenatal and intrapartum stillbirth. As yet, it remains difficult to predict which pregnancies are at greatest risk of stillbirth but with further research, ongoing improvements in antenatal and intrapartum care, and improved patient education, it is anticipated that the incidence in the UK can be substantially reduced.     

Rectovaginal Staphylococcus aureus colonization: is it a neonatal threat?

We sought to determine the rate of Staphylococcus aureus rectovaginal colonization and positive newborn blood cultures. Routinely obtained group B streptococcus (GBS) rectovaginal specimens were cultured for S. aureus using standard microbiology procedures. S. aureus- and GBS-positive blood cultures in infants less than 3 days old were determined from our microbiology database. Overall, 1488 rectovaginal cultures were obtained. Rates of positive GBS, S. aureus, and methicillin-resistant S. aureus (MRSA) cultures were 20.2%, 8.2%, and 1.7%, respectively. Cultures were positive for methicillin-susceptible S. aureus (MSSA) and GBS or MRSA and GBS in 1.6% and 0.3% of women, respectively. There was no association between GBS and MSSA or MRSA. From 1998 to 2008, there were four positive S. aureus blood cultures (0.4/10,000 live births). The rate of early onset GBS-positive blood cultures was 2.8/10,000 live births. S. aureus rectovaginal colonization at 35 to 37 weeks is relatively uncommon and currently does not appear to pose a significant risk of early onset neonatal sepsis.     

Postpartum chills phenomenon: is it a feto-maternal transfusion reaction?

OBJECTIVE: To examine the theory that the postpartum shivering phenomenon is related to feto-maternal bleed during the third stage of labor. METHODS: One hundred laboring low-risk women who had a normal vaginal delivery were observed for the presence of postpartum chills. The duration of the first and second stages of labor changes in body temperature, maternal and fetal blood types and the use of epidural anesthesia were recorded. Following the delivery maternal blood was examined for the presence of fetal red blood cells using the Kleihauer-Betke stain. RESULTS: Complete data was available in 97 patients. Post-partum chills occurred in 31 of them (32%). Women with and without chills were similar in their maternal and gestational age, the use of epidural anesthesia, and length of second stage of labor. Women with chills delivered smaller babies but the difference did not reach significance. Maternal-fetal blood group incompatibility was significantly more common among shivering than non-shivering women (48% vs. 20% respectively, p=0.006). Kleihauer-Betke test was positive in 11 women. The only two women in this group who experienced chills had maternal-fetal blood group incompatibility. CONCLUSION: Post-partum chills are a common phenomenon. It may be the clinical presentation of feto-maternal transfusion reaction. The small number of positive Kleihauer-Betke tests may reflect its low sensitivity in the detection of small feto-maternal bleeds.