Tania Day

Factors associated with the provision of antenatal contraceptive counseling

BACKGROUND A chart review was conducted to evaluate patient and provider characteristics associated with having a documented antenatal plan regarding future contraception. STUDY DESIGN A retrospective chart review of 528 parturients delivering between January and August 2002 was performed. Data obtained from chart review included demographics, antecedent pregnancy outcome, number of prenatal visits, provider type and documentation of an antenatal plan for postpartum contraception. RESULTS Non-Hispanic white women, as compared to other racial/ethnic groups, were more likely to have documented counseling plans (OR 1.5, 95% CI 0.9-2.3), while non-English-speaking women were significantly less likely to have contraceptive plans recorded (OR 0.5, 95% CI 0.3-0.8). Women with recorded antenatal plans attended more prenatal visits (median 10 vs. 8, p < .001). Nurse practitioners were significantly more likely to document antenatal contraceptive counseling than were residents (OR 3.7, 95% CI 2.4-5.5). In the adjusted analysis, the factors most strongly being positively correlated with antenatal documentation included attending > 10 prenatal visits (adjusted OR 6.2, 95% CI 2.9-13.2), being seen by a nurse practitioner (adjusted OR 4.5, 95% CI 2.9-7.0) and being non-English speaking (adjusted OR 0.6, 95% CI 0.3-1.0). CONCLUSION The provision of antenatal contraceptive counseling is associated with certain characteristics, including the patients primary language, the number of prenatal visits and type of provider seen.

Normal vulvar histology: variation by site

Objective The aim of the study was to assess the histology of normal vulvar skin with attention to anatomic location and epithelium type. Materials and Methods We performed a retrospective histologic review of 118 vulvar biopsies and excisions obtained between 2010 and 2014 with adjacent normal skin or mucosa. Exclusions included age younger than 18 years, vestibulectomy, labiaplasty, inflammatory dermatoses, and insufficient normal tissue for assessment. Stratum corneum morphology was assessed as basket weave, compact, or intermediate. Stratum granulosum cell layer number and epithelial thickness were recorded. Dermal lymphocytic infiltrate was described as nil, sparse, moderate, or dense. Fischer exact test, Pearson &khgr;2, and Student t test were used for statistical analysis. Results There were 7 cases from mons pubis, 11 from perineum, 83 from labia, and 17 from vestibule. In the skin, the stratum corneum morphology was basket weave in 31%, compact in 35%, and intermediate in 34%. Stratum corneum at the mons pubis was uniformly basket weave, whereas at perineum, it was either compact or intermediate (7/7 vs 0/11; p < .001); the labia demonstrated all 3 morphologies. Parakeratosis (PK) was identified at the specimen edge in 4 cases of hairless skin and 7 cases of squamous mucosa. Mean epithelial thickness and dermal lymphocytic infiltration were similar in specimens with and without PK. Conclusions Compact stratum corneum of vulvar skin and a zone of PK at the mucocutaneous junction may be normal histological findings. Pathologists need to be aware of site-related differences of the vulvar epithelium to avoid overdiagnosis of pathological conditions.

Vulvar pityriasis versicolor in an immunocompetent woman.

Objective To report a case of isolated vulvar pityriasis versicolor in a 24-year-old healthy woman. Materials and Methods A 24-year-old woman presented with variable color change on the vulva of 8 months in duration. Results Areas of tan and white skin were observed on the mons pubis. The pubic hair had been shaved. Initially, the paler areas were deemed abnormal suggesting vitiligo, but the biopsy showed normal skin including normal numbers of melanocytes. Subsequently, biopsy of the tan area showed pityriasis versicolor. She was successfully treated with topical 2% ketoconazole, with gradual fading of lesions. Conclusions With increased body awareness and the current popularity of pubic hair removal, young women may consult clinicians about color changes on the vulva. Clinicians should be aware that vulvar pityriasis versicolor may occur in healthy women with no other skin involvement.

Should unsatisfactory colposcopy necessitate treatment of cervical intraepithelial neoplasia 1

Objective. To evaluate the prevalence of cervical intraepithelial neoplasia (CIN) 2 or worse among women undergoing cone biopsy for CIN 1, stratified by colposcopic adequacy. Materials and Methods. A cross-sectional cohort study was performed using a colposcopic database of 3,004 women seen between August 1999 and December 2005. Data collected included demographic information, indications for treatment, adequacy of colposcopic examination, and final cone pathology. A satisfactory colposcopy was defined as being able to define the entire squamocolumnar junction and visualize all lesions in their entirety. Descriptive statistics and crude and adjusted odds ratios with 95% confidence intervals were calculated. Results. Of the 440 cone biopsies, 50 (11%) were done for CIN 1, of which 9 (18%) demonstrated CIN 2 or worse, and 23 (46%) were done in the setting of unsatisfactory colposcopy. Compared with women with satisfactory colposcopy, women with unsatisfactory colposcopy were more likely to be older (median age = 33 vs 25 years, p = .01) and to have CIN 1 on endocervical sampling (5/22 [22%] vs 0, p < .01). Persistent (18 months or more) CIN 1 was more commonly encountered in women with satisfactory colposcopy (21/27 [78%] vs 7/23 [30%], p < .01). Women with unsatisfactory colposcopic examinations were at decreased risk of CIN 2+ on final pathology compared with women with satisfactory examinations (1/23 [4%] vs 8/27 [30%], odds ratios = 0.08, 95% confidence intervals = 0.01-0.95). Conclusions. Women with unsatisfactory colposcopy and CIN 1 are unlikely to have high-grade cervical neoplasia on final pathology. For this subset of women, conservative management is preferable to immediate treatment.

Regorafenib-Associated Vulvar Psoriasiform Skin Reaction: Case of the Month from the ISSVD Case Consultation Committee.

CASE A 52-year-old woman presented to an appointment with gynecology 2 weeks after spontaneous drainage of a Bartholin’s abscess. She reported vulvar erythema and pruritus since commencing regorafenib for management of refractory gastrointestinal stromal tumor (GIST) 8 months previously. She experienced regorafenibassociated hand-foot skin reaction (HFSR). Vulvar and HFSR symptoms were worst during weeks 2 and 3 of the 3-on/1-off cyclical regimen. She had no other dermatologic problems or family history of skin disease. Her daily medications included olmesartan, hydrochlorthiazide, lanzoprazole, and olanzapine. Initial examination showed diffuse vulvar erythema. A 1.5-cm tender nodule was palpated at the site of a previous Bartholin’s gland drainage, and the patient was prescribed trimethoprimsulfamethoxazole for suspected infection. A 3-mm punch biopsy was taken of the outer left labium majus, which showed a psoriasiform tissue reaction with regular elongation of rete ridges, parakeratosis, and corneal neutrophils (Figure 1). There was a perivascular lymphocytic infiltrate in the superficial dermis with scattered eosinophils and plasma cells (Figure 2). No tortuous papillary dermal capillaries or related suprapapillary epidermal thinning was seen. The periodic acid-Schiff stain was negative for fungal elements. Management included antihistamines, betamethasone dipropionate ointment, and vulvar care measures. At follow-up examination 10 days later, written consent was obtained for photographs and case report, and examination showed improvement of vulvar erythema. The antihypertensive medication was changed from an angiotensin-receptor blocker, which is associated with psoriasiform eruptions, to a calcium-channel blocker. There was no change in the appearance of the rash after ceasing olmesartan. She attended several visits at different points in the regorafenib cycle; during weeks 2 and 3, there were erythematous plaques over the labia majora and groins, and during “off” weeks, the vulva seemed normal (Figure 3). At the most recent visit, she reported symptoms were manageable with use of daily emollient and intermittent topical corticosteroids.

Una colposcopia no satisfactoria indica la necesidad de aplicar un tratamiento para la neoplasia cervical intraepitelial de grado 1

Objetivo. Evaluar la prevalencia de la neoplasia cervical intraepitelial (CIN) 2 o superior en las mujeres a las que se practica una conización por una CIN 1, estratificadas en función de que la colposcopia haya sido adecuada. Materiales y métodos. Se llevó a cabo un estudio de cohorte transversal mediante una base de datos sobre colposcopias practicadas en 3.004 mujeres visitadas entre agosto de 1999 y diciembre de 2005. Los datos recopilados fueron información demográfica, indicaciones para tratamiento, exploración colposcópica satisfactoria y resultado anatompatológico final de la conización. Una colposcopia satisfactoria se definió como la que permitía definir toda la unión escamoso‐cilíndrica y visualizar todas las lesiones en su totalidad. Se calcularon estadísticas descriptivas y odds ratios brutas y ajustadas con intervalos de confianza del 95%. Resultados. De las 440 conizaciones, 50 (11%) se practicaron por una CIN 1, y nueve de ellas (18%) produjeron un resultado de CIN 2 o superior, y 23 (46%) se realizaron en el contexto de una colposcopia no satisfactoria. En comparación con las mujeres con una colposcopia satisfactoria, fue más probable que las mujeres con una colposcopia no satisfactoria fueran de mayor edad (mediana de edad = 33 frente a 25 años, p = 0,01) y presentaran CIN 1 en las muestras endocervicales obtenidas (5/22 [22%] frente a 0, p <0,01). La CIN 1 persistente (18 meses o más) se observó con mayor frecuencia en mujeres en las que la colposcopia había sido satisfactoria (21/27 [78%] frente a 7/23 [30%], p <0,01). Las mujeres en las que las exploraciones colposcópicas no habían sido satisfactorias estaban sujetas a un riesgo menor de presentar CIN 2 o superior en los resultados anatomopatológicos finales en comparación con las mujeres en las que las exploraciones colposcópicas habían sido satisfactorias (1/23 [4%] frente a 8/27 [30%], odds ratios = 0,08, intervalo de confianza del 95% = 0,01‐0,95). Conclusiones. Es poco probable que las mujeres en las que la colposcopia no ha sido satisfactoria y presentan CIN 1 obtengan un resultado anatomopatológico final de neoplasia cervical de alto grado. Para este subgrupo de mujeres, es preferible una conducta conservadora en vez de un tratamiento inmediato. ▪