Graeme Dennerstein

Evaluation of patch testing in patients with chronic vulvar symptoms

The Dermogynaecology Clinic was established at the Mercy Hospital for Women in 1989. Since its inception, 700 patients have been investigated and 15% were clinically diagnosed as having contact dermatitis. Primary irritant dermatitis was regarded as the common cause but to investigate the place of contact allergy 50 patients were patch tested to a standard battery, medicaments, preservatives, corticosteroids and miscellaneous allergens. Twenty‐one patients (42%) had a total of 44 positive tests. The most common positive reactions were to nickel (22%), cobalt (6%), fragrances (12%). caine mix (6%) and ethylenediamine (8%). Medicaments and fragrances were regarded as important allergens. Corticosteroid and imidazole allergy was not a problem in this series of patients.

Human papillomavirus vulvitis: a new disease or an unfortunate mistake?

Objective To determine whether human papillomavirus (HPV) was responsible for symptoms in women with vulvar pruritus, pain and superficial dyspareunia who had been referred with a diagnosis of HPV vulvar disease made on clinical and/or colposcopic and/or histological grounds.

ANGIOLYMPHOID HYPERPLASIA WITH EOSINOPHILIA OF THE VULVA

Summary: Vulvar angiolymphoid hyperplasia with eosinophilia is a rare benign itchy vascular lesion that, because of its nonspecific clinical features, requires biopsy for accurate diagnosis. Surgical excision is the preferred method of treatment.

Re: Hormones down under: Hormone therapy use after the Women's Health Initiative

At the end of their paper on hormone therapy after the Women’s Health Initiative (WHI), Travers et al. touch on the important issue of systemic versus topical oestrogen for ‘vaginal dryness and associated dyspareunia’, which affected one-tenth of their sample. Does the route of administration matter? The maturation index is a simple and reliable test of vaginal oestrogenisation and can be performed by the clinician in the office. When attempting to answer the above question, often aided by this test, I have learnt that: 1 Arousal failure needs to be considered in most cases irrespective of vaginal oestrogenisation. 2 Topical oestrogens do not always work. 3 At the correct dosage, which can be checked by a serum oestradiol and follicle-stimulating hormone, systemic oestrogen replacement can be guaranteed to oestrogenise the vagina. 4 Topical oestrogens, as with systemic oestrogens, can be used excessively, predisposing the woman to Candida albicans infection. 5 Systemic oestrogen replacement often has extragenital benefits on sexuality which topical therapy cannot produce. 6 Topical oestrogen preparations are capable of producing genital contact dermatitis. These, then, are the considerations I would recommend when deciding whether to treat the postmenopausal woman’s sexual complaint with systemic oestrogen or vaginal oestrogen (never both!) and/or counselling.

Bowel resection for severe endometriosis: An Australian series of 177 cases

We read with great interest the article on the above by Wills et al., because of the rarity of the need for bowel resection for endometriosis. One of us (GD) has only had one such case in 41 years of specialist practice and that was required for obstruction. However, we realise that many of these patients may take themselves directly to specialised units or colorectal surgeons and bypass the gynaecologist. We were also surprised to read the statement in the introduction: ‘As medical treatment is usually unsuccessful ...’ attributed to Thomassin et al. Thomassin et al. based this unsubstantiated statement on their own 27 patients. Their ‘medical therapy’ had consisted of ‘GnRH analogues’ for at least 3 months ‘in all of the women’, ‘progestins’ in 1% and danazol in one patient, the latter two treatments used for an unspecified period. Those who share the concept that the severity of endometriosis is related to the number of ovulations, will agree that 3 months of medical treatment is unlikely to achieve much. Medical therapy is usually required over much longer periods, but may provide very effective relief even from symptoms of severe, deep, infiltrating endometriotic disease. At the same conference in which Wills’ work was presented, a poster was exhibited showing that Depo Provera (DMPA) is successful in relieving the pain of endometriosis in all but one of 39 women treated with DMPA alone, with no significant complications. Surprisingly, Wills does not state the rate of pain relief in their series even though pain was the commonest reason (79.1%) for performing the procedure. However, they did have 16 ‘unintended events’, including three ileostomies. The commonest objection to the long-term use of DMPA is decreased bone mineral density (BMD). We expect to publish data soon showing that this either does not occur or is not of clinical significance, even when DMPA has been used for over 20 years. Four well-recognised professional organisations (World Health Organisation, The Society for Adolescent Medicine, The Society of Obstetrics and Gynaecology of Canada and The American College of Obstetrics and Gynaecology) have advocated the safety of DMPA. These organisations have agreed that ‘there should not be any restriction on the use of DMPA’ and that ‘the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk’. In 2009, a further consensus meeting was called by the National Institute of Public Health of Quebec in Canada. This meeting reviewed the literature and agreed that DMPA use should not be restricted, BMD should not be monitored and routine treatment with vitamin D and calcium should not be instigated solely because a woman is using DMPA. We still have much to learn about the optimal management of endometriosis, be it medical or surgical. It is an unusually difficult area for controlled trials, but this research technique is likely to be the best way forward.

Caudal Analgesia by the Obstetrician

EDITORIAL COMMENT: Not many obstetricians in Australia perform ‘their own’ caudal blocks in patients requiring forceps delivery or manual removal of the placenta. This paper indicates that the practice is safe when training is appropriate and expertise is maintained by regular use of the technique.

Recurrent vulvovaginal candidiasis: A review of guidelines and recommendations

We hope that interest and discussion around transvaginal mesh will ensure that innovation continues. Emerging research around the possible immunological and genetic factors which may determine how an individual reacts to foreign implant such as transvaginal mesh is in its infancy but is most definitely an emerging area of scientific and clinical research. In recent years there has been exciting basic science research that may be the foundation for risk assessment models that the author alludes to and, once clinical research confirms the scientific hypotheses, we may have more solid grounds to predict a woman’s risk of mesh complications.1,2 One particularly interesting finding is that the host response involved in mesh exposure cases is different from that seen in mesh pain complications.3 The modelling publications concerning patient risk of persistent pain after inguinal hernia operations referred to by the author similarly present basic scientific hypotheses that may or may not manifest in clinically useful information. Of the two papers referenced, one presents possible genetic associations with pain and the other identifies preoperative pain and intraoperative nerve damage as risk factors for persistent pain. In our experience, chronic or preexisting pain has always been a relative contraindication for transvaginal meshes as it is well accepted that these women have a high risk of persistent postoperative pain. Neither in abdominal hernia nor pelvic organ prolapse mesh surgery do there currently exist practical and clinically relevant predictive models that allow us to assess an individual’s risk of mesh complications. As we endeavour to find mesh materials that are more biocompatible, research is also striving to identify important genetic and immunological influences in hostmesh interactions, and we agree with the author that this research has the potential to have a significant clinical impact.