Colleen K. Stockdale

2013 Vulvodynia Guideline update.

Abstract Vulvodynia is a complex disorder that can be difficult to treat. Most patients describe it as burning, stinging, irritation, or rawness. Vulvodynia is a costly disease both economically and on its negative impact on patient quality of life. Although many treatment options are available, no one treatment is effective for all patients, thus the need to individualize management. Measures such as gentle vulvar care, medication, biofeedback training, physical therapy, sexual counseling and surgery, as well as complementary and alternative therapies are available to treat the condition with varying success.

2011 ISSVD Terminology and Classification of Vulvar Dermatological Disorders: An Approach to Clinical Diagnosis

Objective The study aimed to formulate an easy clinical approach that may be used by clinicians of all backgrounds to diagnose vulvar dermatological disorders. Materials and Methods The International Society for the Study of Vulvovaginal Disease appointed a committee with multinational members from the fields of dermatology, gynecology, and pathology and charged the committee to formulate a clinically based terminology and classification of vulvar dermatological disorders. The committee carried out its work by way of multiple rounds of e-mails extending over almost 2 year’s time. Results The committee was able to formulate a consensus report containing terminology, classification, and a step-wise approach to clinical diagnosis of vulvar dermatological disorders. This report was presented and approved by the International Society for the Study of Vulvovaginal Disease at the XXI International Congress held in Paris, France, on September 3 to 8, 2011. Conclusions The authors believe that the approach to terminology and classification as well as clinical diagnosis contained in this article allows clinicians to make highly accurate diagnoses of vulvar dermatological disorders within the clinical setting. This, in turn, will reduce the need for referrals and will improve the care for women with most vulvar disorders.

The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions

OBJECTIVES: The impact of terminology for vulvar intraepithelial lesions has been significant over the years, because it has affected diagnosis, treatment, and research. The introduction of the Lower Anogenital Squamous Terminology (LAST) in 2012 raised 2 concerns in relation to vulvar lesions: firstly, the absence of reference to “differentiated vulvar intraepithelial neoplasia” (differentiated VIN) could lead to its being overlooked by health care providers, despite its malignant potential. Secondly, including the term “low-grade squamous intraepithelial lesion” (LSIL) in LAST recreated the potential for overdiagnosis and overtreatment for benign, self-limiting lesions. MATERIALS AND METHODS: The International Society for the Study of Vulvovaginal Disease (ISSVD) assigned the terminology committee the task of developing a terminology to take these issues into consideration. The committee reviewed the development of terminology for vulvar SILs with the previous 2 concerns in mind and reviewed several new terminology options. RESULTS: The final version accepted by the ISSVD contains the following: 1) Low-grade SIL of the vulva or vulvar LSIL, encompassing flat condyloma or human papillomavirus effect. 2) High-grade SIL or vulvar HSIL (which was termed “vulvar intraepithelial neoplasia usual type” in the 2004 ISSVD terminology). 3) Vulvar intraepithelial neoplasia, differentiated type. CONCLUSION: The advantage of the new terminology is that it includes all types of vulvar SILs, it provides a solution to the concerns in relation to the application of LAST to vulvar lesion, and it is in accordance with the World Health Organization classification as well as the LAST, creating unity among clinicians and pathologists.

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia.

IntroductionIn 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Womens Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade. Materials and MethodsThe new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each societys board accepted the new terminology. Results and ConclusionsIn 2015, the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Womens Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions.

Objectives The impact of terminology for vulvar intraepithelial lesions has been significant over the years, because it has affected diagnosis, treatment, and research. The introduction of the Lower Anogenital Squamous Terminology (LAST) in 2012 raised 2 concerns in relation to vulvar lesions: firstly, the absence of reference to “differentiated vulvar intraepithelial neoplasia” (differentiated VIN) could lead to its being overlooked by health care providers, despite its malignant potential. Secondly, including the term “low-grade squamous intraepithelial lesion” (LSIL) in LAST recreated the potential for overdiagnosis and overtreatment for benign, self-limiting lesions. Materials and Methods The International Society for the Study of Vulvovaginal Disease (ISSVD) assigned the terminology committee the task of developing a terminology to take these issues into consideration. The committee reviewed the development of terminology for vulvar SILs with the previous 2 concerns in mind and reviewed several new terminology options. Results The final version accepted by the ISSVD contains the following: •Low-grade SIL of the vulva or vulvar LSIL, encompassing flat condyloma or human papillomavirus effect. •High-grade SIL or vulvar HSIL (which was termed “vulvar intraepithelial neoplasia usual type” in the 2004 ISSVD terminology). •Vulvar intraepithelial neoplasia, differentiated type. Conclusions The advantage of the new terminology is that it includes all types of vulvar SILs, it provides a solution to the concerns in relation to the application of LAST to vulvar lesion, and it is in accordance with the World Health Organization classification as well as the LAST, creating unity among clinicians and pathologists.

Urinary incontinence, depression and posttraumatic stress disorder in women veterans

OBJECTIVE To study associations between urinary incontinence (UI) symptoms, depression, and posttraumatic stress disorder in women veterans. STUDY DESIGN This cross-sectional study enrolled women 20 to 52 years of age registered at 2 midwestern US Veterans Affairs Medical Centers or outlying clinics within 5 years preceding study interview. Participants completed a computer-assisted telephone interview assessing urogynecologic, medical, and mental health. Multivariable analyses studied independent associations between stress and urgency UI and depression and posttraumatic stress disorder. RESULTS Nine hundred sixty-eight women mean aged 38.7 ± 8.7 years were included. Of these, 191 (19.7%) reported urgency/mixed UI and 183 (18.9%) stress UI. Posttraumatic stress disorder (odds ratio, 1.8; 95% confidence interval, 1.0-3.1) but not depression (odds ratio, 1.2; 95% confidence interval, 0.73-2.0) was associated with urgency/mixed UI. Stress UI was not associated with posttraumatic stress disorder or depression. CONCLUSION In women veterans, urgency/mixed UI was associated with posttraumatic stress disorder but not depression.

Preparing for the Next Round of Asccp-sponsored Cervical Screening and Management Guidelines

T he American Society for Colposcopy and Cervical Pathology (ASCCP), in collaboration with the National Cancer Institute, has begun to prepare for the next update to its cervical screening and management consensus guidelines. Here, we describe the current plans for this multiyear process. Since 2001, the ASCCP has sponsored several rounds of cervical consensus guidelines; each has made extensive use of epidemiologic data from clinical trials and epidemiologic studies from the National Cancer Institute and other sources. The recommendations have been developed by expert representatives of many cooperating clinical societies after extensive public comment periods. Initially, the ASCCP-sponsored guidelines concentrated on the management of cytologic and histologic abnormalities found during screening. More recently, the ASCCP has cooperated with the American Cancer Society (ACS) and more than 20 other clinical organizations to consider general population screening issues as well. The next round of guidelines might continue to consider both cervical screening and management of abnormal results, pending discussion and in cooperation with other groups. Although it is undesirable to change clinical recommendations unless necessary, revision is needed soon for several reasons. The introduction of human papillomavirus (HPV) testing into US screening programs almost 15 years ago was a major change; initially, it was not possible to judge how repeated rounds of screening would perform. There are now enough data to judge and guide the realistic clinical performance of multiple rounds of “co-testing” combining HPV testing with cytology. We can also estimate howmultiple rounds of primary screening with HPV tests alonewould perform. Second, young women vaccinated prophylactically against HPV have reached the age of screening, and HPV vaccination will increasingly and profoundly affect screening performance. Given the postvaccination prevalence of precancer, cytology and pooled HPV tests perform less effectively (e.g., they are less predictive of cervical precancer) in vaccinated populations than in unvaccinated populations. In addition, new tests and strategies for triage of screen-positive women have been introduced and evaluated sufficiently to consider their role in new recommendations. Finally, the current guidelines are already very complex but still incomplete. As we strive for even greater precision to maximize the benefits andminimize the harms of screening, producing more algorithm trees is not a practical answer. Given available evidence, it is possible, as explained hereafter, to push simultaneously toward greater precision and simplicity, supported by a computer-based decision tool. The risk database will be publicly available, permitting access to those wishing to use it to create such tools. In preparing for the next round of guidelines, we recognize that several groups offer cervical screening and management recommendations, most prominently the US Preventive Services Task Force, ACS, and the American College of Obstetrics and Gynecology. Consistency in recommendations, preferably unanimity regarding the important issues, is very important. Nonetheless, the ASCCP-sponsored guidelines provide a unique perspective in the following ways. The guidelines aim to be as comprehensive as possible, covering such a large number of specific clinical situations that reliance on data from the reference standard of evidence, randomized clinical trials addressing individual questions, are not conceivable for most recommendations. Less emphasis will be on formal review of individual published studies with grading of the published literature provided by a separate group of evaluators. Instead, observational “big data” as well as trial data, pooled from all available sources, will form the basis of the updated recommendations. Epidemiologic research targeted specifically to support the guidelines will be conducted and reviewed by cervical screening and management experts. The most recent set of ASCCP-sponsored consensus guidelines introduced risk of cervical intraepithelial neoplasia (CIN) 2, CIN 3, adenocarcinoma in situ, and cancer as the unifying principle of the many recommendations and algorithm “trees.” Regardless of the screening test or algorithm (e.g., screening followed by triage), there should be equal management of equal risk. A prime example is the equal management of cytologic low-grade squamous intraepithelial lesion (LSIL) and HPVpositive atypical squamous cells of undetermined significance (atypical squamous cells of undetermined significance [ASC-US]). Anticipated improvements planned for the next set of ASCCP-sponsored guidelines will include the following: A) More detailed risk estimates, for greater numbers of test combinations, and for a greater number of clinical scenarios, such that the guidelines better address the variety of clinical situations EDITORIAL

Vulvar and Vaginal HPV Disease

Human papilloma virus is associated with a multitude of lower genital tract diseases in women in addition to cervical cancer, including genital warts, vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, and some vulvar, vaginal, and anal cancers that are associated with oncogenic subtypes. The degree to which HPV manifests pathology depends on viral type, host immune response, and local environmental factors. This article reviews the evaluation and management of the following vulvar and vaginal human papilloma virus diseases: condyloma, vulvar intraepithelial neoplasia, and vaginal intraepithelial neoplasia. Included is a brief discussion of the association with vulvar and vaginal cancer.

Clinical spectrum of desquamative inflammatory vaginitis.

Desquamative inflammatory vaginitis (DIV) is a rare chronic clinical syndrome of unknown etiology characterized by profuse purulent vaginal discharge, diffuse exudative vaginitis, epithelial cell exfoliation, and pain. A diagnosis of DIV is often missed by even experienced practitioners owing to its rarity and its clinical and laboratory presentation similar to other inflammatory vulvovaginal disorders. Although DIV is difficult to treat and often requires long-term therapy for maintenance, successful therapy has been reported with topical steroids and clindamycin.

Differences in Cervical Cytologic and Histologic Findings Between Women Using Depot-Medroxyprogesterone Acetate and Oral Contraceptives

Objective. This study aimed to compare cervical cytologic and histologic findings between women using depot-medroxyprogesterone acetate (DMPA) and oral contraceptives (OCs) referred for colposcopy and to determine whether there were differences in the occurrence of false-positive cytologic finding between the 2 contraceptive groups. Materials and Methods. Retrospective cohort of 1,569 premenopausal women using either DMPA or OC who were evaluated for abnormal cervical cytologic findings. Cytologic and histologic data were collected in conjunction with routine gynecologic examinations or follow-up colposcopic evaluations. &khgr;2 tests were used to determine differences in cervical cytologic and histologic findings and the proportion of false-positive results across contraceptive groups. Nominal logistic regression was used to evaluate the association between contraceptive use, cervical, and histologic abnormalities while controlling or age and smoking status. Results. The mean age of all participants was 23.5 years, with no significant difference between OC (n = 1194) and DMPA (n = 375) users. Although there were no differences in the proportion of false-positive cytologic results (21.8% overall), DMPA users were more likely to smoke (p < .001), have atypical glandular cell (AGC) on referral cytology (p < .001), and have histologic confirmation of cervical intraepithelial neoplasia 2, 3 (p = .004). Users of DMPA remained more likely to have AGC cytology after considering smoking status; however, cervical intraepithelial neoplasia 2, 3 was found to be associated with smoking status and not use of DMPA. Conclusions. We found no difference in the proportion of false-positive cytologic results between DMPA and OC users referred for evaluation of abnormal cytology. Users of DMPA were more likely to have AGC, which necessitates a more comprehensive evaluation.