Ospemifene plus fractional CO2 laser: a powerful strategy to treat postmenopausal vulvar pain

Abstract

This study is a single-center, retrospective analysis of postmenopausal women presenting with dyspareunia and vulvar pain, aiming to evaluate relative effectiveness of vestibular CO₂ laser therapy as a treatment. Three monthly sessions of laser were performed to each patient and thereafter a three-months follow-up was stablished. A total number of 72 patients undergoing vestibular laser treatment were recruited from patient files in the period between 2016 and 2018. Among these, 39 women also received a concomitant treatment with ospemifene (60?mg/day) during the study period. There was a statistically significant reduction of all the symptoms in both groups up to the three month follow-up. Regarding dryness and dyspareunia, the relief tent to be more prominent in the ospemifene?+?laser group at all follow-ups and remained statistically significant at three-month follow-up. Specifically, vestibular dryness was significantly lower in the ospemifene?+?laser group compared with the laser treatment group (?87% vs???34%, respectively), and the vestibular health score started declining faster in the ospemifene?+?laser group. Although, additional research is needed to understand the mechanism of action, our data shows that a combination regimen of laser and ospemifene may improve clinical effectiveness for long-term treatment of symptoms associated with the under-recognized genitourinary syndrome of menopause.     

Vestibulodynia-A subset of vulvar vestibulitis or a novel syndrome?

OBJECTIVE: Our purpose was to recognize special features of women with both vestibulitis and constant vulvar pain (vestibulodynia) and to determine whether vestibulodynia is a separate disease entity or a subset of vestibulitis. STUDY DESIGN: Ninety-one women with severe vulvar vestibulitis underwent perineoplasty by a single surgeon during 1992 to 1995. Twenty-five (27%) of them who had vestibulodynia were compared with 66 (73%) who had dyspareunia alone. With univariate and then multivariate analysis, the two groups were compared with regard to demographic, social, and medical variables, the presence of human papillomavirus deoxyribonucleic acid, physical findings in the vestibule, and surgical outcome. RESULTS: The vestibulodynia and vestibulitis groups differed in age (30.5 ± 10.6 years vs 24.7 ± 6.2 years respectively), as well as in marital status (married, 44% vs 18%, respectively), nonuse of contraception (20% vs 1%, respectively), presence of human papillomavirus deoxyribonucleic acid in the vestibule (80% vs 48%, respectively), and failure of surgical treatment (incomplete response rate, 64% vs 2%, respectively). With multivariate analysis, patients with human papillomavirus deoxyribonucleic acid present in the vestibule have an odds ratio of 5.44 (95% confidence interval, 1.45 to 20.33) of belonging to the group with vestibulodynia, whereas dysuria and age have odds ratios of 3.70 (95% confidence interval 1.09 to 12.55) and 1.14 (95% confidence interval 1.04 to 1.24), respectively. CONCLUSIONS: Vestibulodynia is a unique syndrome in that it affects women who are older than those who have vestibulitis alone and it is associated with human papillomavirus deoxyribonucleic acid, dysuria, and a higher surgical failure rate than that for vestibulitis.(Am J Obstet Gynecol 1997;177:43)     

Psychological profiles among women with vulvar vestibulitis syndrome: a chart review

The purpose of this study was to assess the prevalence and type of psychological distress in women with vulvar vestibulitis syndrome (VVS), A retrospective chart review was conducted of all women receiving a diagnosis of VVS referred to a tertiary care facility during a two-year period. Brief psychological questionnaires, including the Personality Assessment Screener, Fear of Negative Evaluation Scale, Golombok-Rust Inventory of Sexual Satisfaction, and the Phobia Rating Scale were administered.

Fifty-consecutive cases were reviewed along with 12-15 month follow-up data for 41 cases. Phobic anxiety to vaginal touch or entry was significantly higher in women with VVS than normative data. Fear of Negative Evaluation was a strong associated feature, and for 30% approached clinically significant levels. Twenty-six percent showed a moderate, while another 26% showed a mild clinically distressed profile. Negative affect and social withdrawal were among the most frequently endorsed variables. Improvement in allodynia and intercourse were both related to these psychological variables, and a multiple regression analysis supported the use of psychological instruments in addition to standard medical assessment.

A subgroup of women with VVS display clinically significant broad based psychological distress that warrants additional assessment. The use of psychological questionnaires in addition to medical assessment of women with VVS may provide valuable information predictive of treatment needs and response.     

A treatment model for anxiety-related sexual dysfunctions using mindfulness meditation within a sex-positive framework

In this article, we propose a clinical model for treating anxiety-related sexual dysfunctions that hinges on the use of mindfulness meditation practices. First, theoretical and empirical evidence for anxiety as either a cause or condition of several different sexual dysfunctions is provided. Next, the concept of mindfulness and the research that supports the use of mindfulness meditation practices in addressing anxiety are explained. The inherent link between mindfulness and sex-positivity is also addressed while acknowledging the need to emphasize both mindfulness and sex-positivity in therapy. The proposed model for the treatment of anxiety-related sexual dysfunctions using mindfulness practices within a sex-positive framework is outlined. It utilizes mindfulness-based practices such as body scan meditation and sitting meditation as well as several preexisting sex therapy interventions, including directed masturbation and sensate focus assignments. A case study is provided as an example of the progression of therapy and as a demonstration of the clinical viability of the model. Ultimately, this model illustrates a potential way in which mindfulness practices can be utilized within a sex-positive approach to sex therapy.     

The female sexual pain disorders: genital pain or sexual dysfunction?

Vaginismus and dyspareunia have been typically classified as sexual dysfunctions. In practice and research, this conceptualization has led to a focus on sexual and interpersonal issues after biological causes were excluded. Although this approach has been very useful, it has not led to significant theoretical or therapeutic progress in the last 20 years. We propose a reconceptualization of vaginismus and dyspareunia as pain disorders that interfere with sexuality rather than as sexual disorders characterized by pain. This reconceptualization focuses the clinician and researcher on the central phenomenon—pain. It also suggests new approaches to research and treatment. Data from diagnostic, etiologic, and therapeutic studies will be presented to illustrate these points.     

Uterine fibroids and gynecologic pain symptoms in a population-based study

OBJECTIVE: To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids. DESIGN: Population-based cross-sectional study. SETTING: Desio, Italy. PATIENT(S): Six hundred thirty-five non-care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale. RESULT(S): Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9-8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9-7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5-2.6). Number and total volume of fibroids were not related to pain. CONCLUSION(S): This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non-care-seeking population may be different from that of a clinic population.     

Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis

OBJECTIVE: To investigate whether specific types of pelvic pain are correlated with the anatomic locations of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective data analysis. SETTING: University tertiary referral center. PATIENT(S): Two hundred and twenty-five women with pelvic pain symptoms and DIE. INTERVENTION(S): During surgery, we recorded the anatomic locations of DIE implants and associated endometriosis. MAIN OUTCOME MEASURE(S): We studied the incidence of pelvic pain symptoms including severe dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms as related to the location of DIE. RESULT(S): The frequency of severe dysmenorrhea increased with Douglas pouch adhesions and decreased with parity. The frequency of dyspareunia increased with a uterosacral ligament DIE location and decreased when it involved the bladder. The frequency of noncyclic chronic pelvic pain was higher when it involved the bowel and was lower for women who were treated for infertility. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder and less frequent in women with a lower body mass index. Gastrointestinal symptoms were associated with bowel or vaginal DIE locations. CONCLUSION(S): The types of pelvic pain are related to the anatomic location of DIE. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected DIE.     

When Pleasure Causes Pain: Living with Interstitial Cystitis

Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder wall associated with genital and bladder pain, urgency, and dyspareunia. Characterized by sterile urine culture, IC is poorly understood and resistant to treatment. This article contextualizes patients' experiences from the standpoint of age, ethnicity, gender, socioeconomic status, and the experience of concomitant disease. More than 90 percent of interstitial cystitis patients are women, an alarming number of whom have been misdiagnosed as having psychiatric disorders. Medical diagnosis and treatment are discussed from a feminist perspective. The sexual functioning of persons with IC is discussed in depth. Topics touched upon include menstrual cycle variations and pregnancy, sexual desire, pain during sexual activity, sexual side-effects of medications, sexual history, and sexual self-care.