A deficiency in interferon-alpha production in women with vulvar vestibulitis

Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia

INTRODUCTION

Vulvodynia is a debilitating, chronic vulvar pain condition. Community-based case-control studies have consistently shown associations between early-life chronic stressors and vulvodynia onset.

AIM

We examined rumination as a specific stress response involved in the psychobiological mechanism of vulvodynia.

METHODS

A psychosocial survey with questions specific to early-life traumatic events and rumination were administered to 185 matched case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between rumination constructs (ie, total rumination, emotion-focused, instrumental, and searching for meaning) and vulvodynia onset. Conditional logistic regression was also used to determine whether these associations depended on early-life stressors (ie, severity of childhood abuse and of self-reported antecedent traumatic events). Age at interview, antecedent pain disorders, any childhood abuse, and antecedent psychiatric morbidity were included as covariates.

MAIN OUTCOME MEASURES

We estimated the odds of rumination in relation to the onset of vulvodynia within a community-based and clinically confirmed sample of women with and without vulvodynia.

RESULTS

Vulvodynia was associated with the highest tertile of emotion-focused (odds ratio [OR] = 2.1; 95% CI = 1.2, 3.2) and instrumental (OR = 2.1; 95% CI = 1.1, 4.0) rumination. These associations were attenuated after additional adjustment for antecedent psychiatric morbidity. Among women who reported rumination about early-life stressors before vulvar pain in cases or matched reference age in control subjects, those with vulvodynia were >2 times more likely to report the highest tertile of total rumination (OR = 2.3; 95% CI = 1.1, 5.0) compared with those without vulvodynia.

CLINICAL IMPLICATIONS

Healthcare providers may be able to identify subsets of women who could benefit from preventive measures before the development of vulvodynia.

STRENGTH & LIMITATIONS

This is the first study to use a community-based and clinically confirmed sample of women with and without vulvodynia to examine the associations between rumination about early-life trauma and the onset of vulvodynia. However, as with all retrospective studies, the reporting of information (eg, traumatic events) was subject to recall bias and misclassification.

CONCLUSION

Our findings indicate that a prolonged cognitive stress response (ie, rumination) may be 1 important mechanism by which early-life chronic stressors contribute to the onset vulvodynia. Prospective studies are recommended to examine whether and how cognitive, affective, and physiological components of prolonged stress responses interact to influence the development of vulvodynia. Understanding both the psychobiological and behavioral mechanisms may help in addressing and treating individuals to potentially reverse the development of vulvodynia. Khandker M, Brady SS, Rydell SA, et al. Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia. J Sex Med 2019;16:880-890.

Catechol-O-methyltransferase gene polymorphism and vulvar pain in women with vulvodynia

BACKGROUND

The underlying causes of vulvar pain in women with vulvodynia remain poorly understood. Catechol-O-methyltransferase, an enzyme that metabolizes catecholamines, is a neuromodulator that is involved with perception and sensitivity to pain. The catechol-O-methyltransferase gene is polymorphic, and a single nucleotide polymorphism is associated with low activity and heightened pain sensitivity. The variant allele that encodes this polymorphism commonly is called the "L allele" because of its low enzyme activity as opposed to the normal H (high activity) allele.

OBJECTIVE

The methionine-containing catechol-O-methyltransferase protein coded by the L allele results in elevated catecholamine levels, reduced inactivation of the dopaminergic and adrenergic systems, and increased sensitivity to pain. This polymorphism not only may decrease the pain threshold in response to acute pain but also may facilitate the development of chronic pain. Therefore, the objective of our study was to assess whether a variation in the catechol-O-methyltransferase genotype is involved in increased pain sensitivity in women with vulvodynia.

STUDY DESIGN

We conducted a prospective cohort study.

METHODS

Buccal swabs were collected from 167 white women with vulvodynia and 107 control subjects; the DNA was tested for a single nucleotide polymorphism at position 158 (rs4680) in the catechol-O-methyltransferase gene.

RESULTS

Women with vulvodynia had a marginally increased, yet not significant, prevalence of the catechol-O-methyltransferase genotype that is associated with high activity of the coded protein: 32.9% in the women with vulvodynia, as opposed to 21.5% in the control subjects (odds ratio, 1.80; 95% confidence interval, 1.02-3.15). Subgrouping the cases based on pain frequency revealed that the elevated occurrence of this catechol-O-methyltransferase genotype was present in 40.6% of the subset of women who experienced pain only with sexual intercourse vs only 21.5% of control subjects (odds ratio, 2.50; 95% confidence interval, 1.27-4.93). Also, women with primary vulvodynia had a significantly higher prevalence of the H allele than did the control subjects (62.9% vs 48.1%; odds ratio, 1.82; 95% confidence interval, 1.05-3.17).

CONCLUSION

Increased pain sensitivity in women with vulvodynia is not due to a genetically determined low catechol-O-methyltransferase enzyme activity. Other mechanisms may account for alterations in catechol-O-methyltransferase activity in women with pain that is limited to intercourse or primary vulvodynia that contributes to pain sensitivity.

Recent advances in understanding provoked vestibulodynia

Vulvodynia refers to pain in the vulva of at least 3 months’ duration in the absence of a recognized underlying cause. Provoked, localized vestibulodynia is the term used to describe superficial pain confined to the vulvar vestibule, provoked by touch. This review will focus on provoked vestibulodynia with regard to its suggested causative factors and will discuss the role of inflammation, vulvovaginal infections, mucosal nerve fiber proliferation, hormonal associations, central pain mechanisms, pelvic floor muscle dysfunction, and genetic factors.

Clinical observations, epidemiological studies, and data from basic research emphasize the heterogeneity of vulvar pain syndromes. There is a critical need to perform prospective, longitudinal studies that will allow better diagnostic criteria and subgrouping of patients that would lead to improvements in our understanding of provoked vestibulodynia and its treatment.

Activation of vestibule-associated lymphoid tissue in localized provoked vulvodynia

OBJECTIVE

Localized provoked vulvodynia (LPV) may have inflammatory etiology. We wanted to find out whether the cell-mediated immune system becomes activated in the vestibular mucosa in LPV.

STUDY DESIGN

This was a controlled cross-sectional study. Vestibular mucosal specimens were obtained from 27 patients with severe LPV and 15 controls. Detailed clinical history of the patients was obtained. For immunohistochemistry, antibodies against CD3 (T cells), CD20 (B cells), IgA (mucosal plasma cells), CD163 (dendritic cells [DCs]), CD68 (macrophages), and CD117 (mast cells) were employed. Mann-Whitney U test and χ(2) test were used for statistical analyses.

RESULTS

More B lymphocytes and mature mucosal IgA-plasma cells were found in patients than in controls (P < .001 and P < .001, respectively). In LPV samples, B and T cells were arranged into germinal centers representing local immune activation. Germinal centers were not seen in controls. Antigen-presenting DCs and macrophages were found both in patients and controls with similar densities. DCs were found to extend their dendrites into the luminal space through an intact epithelium. Similar amounts of mast cells were found evenly scattered throughout the stroma of vestibular mucosa of both patients and controls.

CONCLUSION

We demonstrate here local organized vestibule-associated lymphoid tissue analogous to mucosa-associated lymphoid tissue. Vestibule-associated lymphoid tissue may emerge as a response to local infection or inflammation in LPV.

Is chronic stress during childhood associated with adult-onset vulvodynia?

BACKGROUND

Vulvodynia is an unexplained chronic vulvar pain condition. Case-control studies provide opportunities to examine potential mechanisms by which vulvodynia may develop. Findings inform etiological models that can be tested in subsequent prospective studies.

METHODS

A survey of interpersonal relationships and the Structured Clinical Interview for DSM-IV Axis I Disorders was administered to 215 case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between affect-based chronic stressors (i.e., living in fear of abuse, perceived abuse, and antecedent mood disorders) with vulvodynia. These associations were then examined among women with and without a history of childhood abuse.

RESULTS

Among women with a history of severe childhood abuse, those with vulvodynia had three times the odds of living in fear of any abuse compared to women without vulvodynia (95% confidence interval: 1.0, 11.0), after adjustment for childhood poverty. Among women with no history of childhood abuse, those with vulvodynia had over six times the odds of antecedent mood disorder compared to women without vulvodynia (95% confidence interval: 1.9,19.6).

CONCLUSION

Our findings suggest that affect-based chronic stressors may be important to the psychobiological mechanisms of vulvodynia. Prospective studies are recommended to test biopsychosocial models of the etiology of vulvodynia.

Vulvodynia

Vulvodynia is a complex disorder reported by up to 16% of women in the general population. While most patients describe it as burning, stinging, irritation, or rawness, it is underreported and underrecognized by providers. Vulvodynia is costly both economically and psychologically due to its negative impact on quality of life. Vulvodynia is a diagnosis of exclusion with unknown etiology and may involve multiple sources of pain in the same woman. Thus, there are no clinical or histopathologic criteria for the diagnosis other than consideration and careful evaluation to exclude other causes of pain. Successful therapy often requires a multidisciplinary approach with more than one therapeutic intervention to address the physical, psychological, psychosexual, and relationship components.

A pig tonsil cell culture model for evaluating oral, low-dose IFN-α treatments

Oral, low-dose IFN-α treatments proved effective in several models of viral infections and immunopathological conditions. Also, they do not give rise to the serious side effects observed after parenteral inoculation of high doses (10(5)U/kg b.w. and higher). There is convincing evidence that such treatments work through an early, effective interaction with oral lymphoid tissues before the IFN-α molecules are rapidly destroyed by gut enzymes. Yet, the paucity of detailed information about these crucial interactions and the lack of recognized in vitro models hamper the development of proper administration protocols. On the basis of a previous study, we developed an in vitro model of interaction between different types of human and porcine IFNs-α at low/moderate concentrations and pig tonsil cells. The IFNs-α under study showed different properties with respect to three fundamental control actions: (1) IgA release in culture, (2) release of natural antimicrobial compounds, and (3) homeostatic regulation of the inflammatory response. This was checked in pig intestinal epithelial cells (IPEC-J2 cell line) treated with supernatants of control and IFN α-treated tonsil cell cultures, respectively, in terms of inflammatory cytokine and chemokine responses. Some IFNs-α caused a significant inhibition of IL-8 (protein release and gene expression) and beta-defensin 1 (gene expression) probably through second messengers released by IFN α-treated tonsil cells. Interestingly, a human lymphoblastoid IFN-α under study caused the decrease of polyclonal IgA release by pig tonsil cells and significantly stimulated the in vitro recall antibody response of swine PBMC to Foot-and-Mouth Disease virus. The modulation of IgA and antibacterial compounds was accompanied by an anti-inflammatory control action at the same, low to moderate IFN-α concentrations (1-100 U/ml). This highlights the very foundation of the homeostatic control actions performed by Type I IFNs: to promote an effective host response to infectious and non-infectious stressors and to turn off noxious inflammatory responses associated with tissue damage and waste of metabolic energy. The described tonsil cell model in vitro can be conducive to a further development of oral cytokine treatments in humans and animals in the "one health" conceptual framework.

The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle

INTRODUCTION

Optimal management of provoked vestibulodynia (PVD), thought to be the most common form of chronic dyspareunia, is unclear.

AIM

To integrate recent brain data on chronic pain circuitry with stress-induced neuroendocrine mechanisms in the skin and the stress burden (allostatic load) of women with PVD; to also clarify the typical chronicity and negative sexual sequelae associated with PVD; and then review modulation of pain circuitry by cognitive therapy and mindfulness practice and apply to PVD management. Methods.  Review of scientific publications in the areas of sexual medicine, pain, brain imaging, gynecology, stress response, mindfulness, and cognitive behavioral therapy (CBT).

MAIN OUTCOME MEASURES

(i) A model of PVD to reflect its etiology, typical chronicity, and the detrimental effects on sexual function; (ii) Interventions of sexual rehabilitation based on principles underlying changes associated with CBT and mindfulness practice.

RESULTS

A model emerges which reflects how stress-induced changes of pain amplification (central sensitization), characteristic of chronic pain conditions, may impair sexual response in addition to sexual dysfunction that arises from conscious pain avoidance and/or fear-related inattention to sexual cues. Stress from low self-acceptance may be a major component of the allostatic load present in women with PVD, only to be exacerbated by the sexual dysfunction precipitated by the pain of intercourse. Mindfulness-based CBT appears promising to target both the pain and sexual suffering from PVD.

CONCLUSION

New findings on brain activity associated with recurrent clinical pain, functional brain changes associated with CBT and mindfulness, plus new data on stress systems within the skin along with data on increased stress load in women with PVD, support the use of mindfulness-based CBT for the recurrent pain and sexual suffering from PVD.

Reverse transcription real-time PCR for detection of porcine interferon α and β genes

A few studies provided convincing evidence of constitutive expression of type I interferons (IFNs) in humans and mice, and of the steady-state role of these cytokines under health conditions. These results were later confirmed in pigs, too. In line with this tenet, low levels of IFN-α/β can be detected in swine tissues in the absence of any specific inducer. These studies are compounded by the utmost complexity of type I IFNs (including among others 17 IFN-α genes in pigs), which demands proper research tools. This prompted us to analyse the available protocols and to develop a relevant, robust, reverse transcription (RT) real-time polymerase chain reaction (PCR) detection system for the amplification of porcine IFN-α/β genes. The adopted test procedure is user-friendly and provides the complete panel of gene expression of one subject in a microtitre plate. Also, a proper use of PCR fluorochromes (SYBR(®) versus EvaGreen(®) supermix) enables users to adopt proper test protocols in case of low-expression porcine IFN-α genes. This is accounted for by the much higher sensitivity of the test protocol with EvaGreen(®) supermix. Interestingly, IFN-β showed the highest frequency of constitutive expression, in agreement with its definition of 'immediate early' gene in both humans and mice. Results indicate that the outlined procedure can detect both constitutively expressed and virus-induced IFN-α/β genes, as well as the impact of environmental, non-infectious stressors on the previous profile of constitutive expression.

Differences in primary compared with secondary vestibulodynia by immunohistochemistry

OBJECTIVE

To assess whether primary and secondary vestibulodynia represent different pathologic pathways.

METHODS

This was an analysis of archived vestibulectomy specimens from 88 premenopausal women with vestibulodynia (2002-2008). Patient records were reviewed to classify the type of vestibulodynia, duration of symptoms, and hormone status. Histologic sections were stained for hematoxylin and eosin to grade inflammation, S100 to highlight nerves, CD117 for mast cells, estrogen receptor α, and progesterone receptor. Differences between primary and secondary vestibulodynia were tested by t tests, chi-square analysis, and linear and logistic regression.

RESULTS

Primary vestibulodynia showed significant neural hypertrophy and hyperplasia (P=.02, adjusted odds ratio [OR] 3.01, 95% confidence interval [CI] 1.2-7.6) and increased progesterone receptor nuclear immunostaining (P=.004, adjusted OR 3.94, CI 1.6-9.9) compared with secondary vestibulodynia. Estrogen receptor α expression was also greater in primary vestibulodynia when symptom diagnosis was less than 5 years (P=.004, adjusted OR 5.53 CI 1.71-17.91).

CONCLUSION

Primary and secondary vestibulodynia have significantly different histologic features, suggesting that they may have separate mechanistic pathways. Clinically, this may mean the discovery of distinct conditions.

Histologic and receptor analysis of primary and secondary vestibulodynia and controls: a prospective study

OBJECTIVE

The objective of the study was to assess the association between hormone receptor densities, pain nerves, and inflammation in vestibulodynia patients.

STUDY DESIGN

In a prospective study, tender and nontender biopsies from 10 primary and 10 secondary vestibulodynia patients were compared with biopsies in 4 nontender controls. Hormone receptors were evaluated using immunohistochemistry for estrogen receptor-alpha and -beta, androgen, and progesterone receptors. Inflammation, nerves, and mast cells were assessed histologically. Statistical analysis was by Fisher's exact test, analysis of variance, paired Student t test, and Wilcoxon rank test.

RESULTS

Tender sites from primary vestibulodynia had increased nerve density compared with secondary and control biopsies (P = .01). Tender sites in secondary vestibulodynia had more lymphocytes than tender primary sites and control biopsies (P < .0001). Mast cells were increased in tender sites compared with nontender and controls. There were no differences in hormone receptor expression.

CONCLUSION

Markers of inflammation differed between primary and secondary vestibulodynia and controls.

Chronic Pain of the Vulva without Dermatologic Manifestations: Distinguishing among a Spectrum of clinical Disorders

The causes of chronic vulvar pain are many and when not accompanied by obvious physical signs they are difficult to unravel. Many common vulvar dermatoses can manifest without obvious erythema or mucocutaneous lesions, as can some less common disorders of both infectious and allergic origin. In addition localized and generalized vulvar dysesthesia, recently defined chronic pain syndromes of neurogenic origin, can also occur in the vulvar area.

Chronic vulvovaginal symptoms in early stages are often presumptuously labeled as vulvovaginal candidiasis (VVC) by patients and clinicians alike, which can delay accurate diagnosis. When presented with chronic vulvar pain unaccompanied by verifiable signs, the clinician must effect a sensitive integration of a detailed medical history, including temporal associations of all potential exposures, with more definitive diagnostic tools. Effective use of those available tools can improve initial diagnosis, thus allowing prompt initiation of effective therapy. Optimal therapy will recognize the significant psychological distress that accompanies any chronic pain syndrome.

Association between primary vulvar vestibulitis syndrome, defective induction of tumor necrosis factor-alpha, and carriage of the mannose-binding lectin codon 54 gene polymorphism

OBJECTIVE

We evaluated whether women with vulvar vestibulitis syndrome (VVS) could be subdivided on the basis of genotyping the polymorphic mannose-binding lectin (MBL) gene.

STUDY DESIGN

DNA from 123 women with VVS was tested for a single nucleotide polymorphism at codon 54 of the MBL gene. Blood samples from 86 of the women were evaluated for ex vivo tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 receptor antagonist (IL-1ra) production in response to Candida albicans, gram-positive peptidoglycan, and gram-negative lipopolysaccharide. Associations between laboratory findings and clinical characteristics were analyzed.

RESULTS

The variant MBL*B allele was identified in 33 subjects (26.8%). This polymorphism was more prevalent in women whose symptoms developed at their first act of sexual intercourse (primary VVS, 40.9%), as opposed to women with secondary VVS (16.3%; P = .01). Ex vivo TNF-alpha production, but not IL-1ra production, was reduced in MBL*B carriers as compared with MBL*A homozygotes (P < or = .03).

CONCLUSION

The MBL gene polymorphism is associated with the development of primary VVS and a reduced capacity for TNF-alpha production in response to microbial components.

The role of IFN-alpha as homeostatic agent in the inflammatory response: a balance between danger and response?

Interferon-alpha (IFN-alpha) is thought of by most immunologists as a fundamental component of the antiviral innate immune response, with other, accessory properties. Several lines of evidence point to a fundamental reappraisal of this conceptual framework because it may neglect other crucial functions of this cytokine under both health and disease conditions. Among these, a regulatory role in the inflammatory response is probably of paramount importance, as shown by in vivo and in vitro studies on humans, pets, and farm and laboratory animals. This role would not conflict with the main functions of IFN-alpha in the innate immune system and would complement these in line with major, evolution-based needs of the host. A hinge role of IFN-alpha between innate and adaptive immunity was recognized in the past on the basis of compelling evidence. This concept should now be widened; not only does IFN-alpha act to trigger, amplify, and sustain the different phases of the immune response, but it could also promote a substantial balance between danger and inflammatory response when an infectious challenge is either declining or completely over.

Sexual sequelae of general medical disorders

That sexual symptoms can signal serious underlying disease confirms the importance of sexual enquiry as an integral component of medical assessment. Data on sexual function are sparse in some medical specialties. However, increased scientific understanding of the central and peripheral physiology of sexual response could help to identify the pathophysiology of sexual dysfunction from disease and medical interventions, and also to ameliorate or prevent some dysfunctions. Many common general medical disorders have negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex. Chronic disease also interferes indirectly with sexual function, by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency. Current approaches to assessment of sexual dysfunction are based on models that combine psychological and biological aspects.

Vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is one of the most common causes of genital pain and pain with sexual intercourse, affecting up to 15% of women. The syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to palpation with a cotton swab, and often subtle physical findings confined to vestibular erythema. The etiology of VVS is unknown. However, it is probably best to consider VVS as a chronic local inflammatory condition with a wide variety of etiologic causes. The heterogeneity of potential etiologies for VVS results in the use of multiple treatment regimens in clinical practice. Scientifically rigorous studies are sorely needed to determine the best treatment approach.

A Conceptual Model for the Pathophysiology of Vulvar Vestibulitis Syndrome

Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorder-akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)-that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that vulvar vestibulitis is common; recall that the disorder has three major pathophysiological pathways and that understanding of these pathways is important in selecting treatment options, and explain that the clinician must attempt to properly classify the clinical presentations of the disorder.

Vulvar vestibulitis syndrome: A review

Vulvar vestibulitis syndrome (VVS) is a perplexing disease involving pain limited to the vulvar vestibule without objective clinical findings to explain the symptoms. The condition impairs sexual function and creates significant psychological distress. Its cause is unknown, and few randomized studies exist on the efficacy of interventions. This article reviews disease characteristics, possible etiologies, and approaches to management.

Adult-onset vulvodynia in relation to childhood violence victimization

Researchers have failed to find a consistent association between childhood victimization and vulvodynia, a debilitating, unexplained vulvar pain condition. However, selection bias associated with case ascertainment, and differential reporting bias between clinic-based cases and controls, may explain in part the inconsistent findings. In 2000-2003, the authors identified 125 women experiencing symptoms of vulvar pain consistent with vulvodynia and 125 age- and community-matched controls from the Boston, Massachusetts-area general population. Telephone-administered questionnaires were used to obtain medical, psychiatric, and reproductive histories. Self-administered surveys assessed childhood exposure (age <12 years) to physical and sexual abuse and to poor family support. After author adjustment for socioeconomic position, women with vulvar pain versus controls were 2.6 times more likely to report never/rarely receiving childhood family support, such as comfort, encouragement, and love (95% confidence interval (CI): 1.3, 5.1). Adult-onset vulvodynia was strongly associated with abuse as a child more than a few times physically (odds ratio (OR) = 4.1, 95% CI: 1.7, 10.0) or sexually (OR = 6.5, 95% CI: 1.2, 35.1). When abused women were compared with those with no history of abuse, the association was largely confined to those harmed by a primary family member (OR = 3.6, 95% CI: 1.6, 8.0 for physical abuse; OR = 4.4, 95% CI: 0.9, 22.9 for sexual abuse). Additional population-based studies of clinically confirmed cases of vulvodynia are needed to replicate this association.

The Vulvodynia Guideline

OBJECTIVE

To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia.

MATERIALS AND METHODS

Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition.

RESULTS

Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient.

CONCLUSIONS

Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Altered distribution of mannose-binding lectin alleles at exon I codon 54 in women with vulvar vestibulitis syndrome

OBJECTIVES

Mannose-binding lectin (MBL) is active in the innate immune defense against microorganisms. In this study, we determined whether vulvar vestibulitis syndrome, a disorder of unknown etiology, was associated with an altered distribution of MBL alleles.

STUDY DESIGN

Buccal swabs were obtained from women with vulvar vestibulitis syndrome in New York (62) and from 2 cities in Sweden (60), as well as control women in New York (48) and Sweden (51). DNA was tested for a single nucleotide polymorphism at codon 54 in exon I by polymerase chain reaction, endonuclease digestion, and gel electrophoresis. Blood samples were also obtained from the New York women and tested by ELISA for plasma MBL concentrations. The relationships between genotype, allele frequencies, blood MBL levels, and diagnosis were analyzed by Fisher exact test and one-way analysis of variance.

RESULTS

The variant MBL allele, MBL*B, was detected in 35.5% and 26.7% of vulvar vestibulitis patients from New York and Sweden, respectively. Only 12.5% of New York controls (P=.007) and 9.8% of Swedish controls (P=.01) were MBL*2-positive. All women, with one exception, who were positive for MBL*B were MBL*A/MBL*B heterozygotes. Women who carried MBL*B had almost a 10-fold reduction in median plasma MBL concentrations (278 ng/mL), as opposed to women who were MBL*A homozygotes (1980 ng/mL) (P < .0001).

CONCLUSION

MBL*B carriage and reduced plasma MBL levels are more common in women with vulvar vestibulitis syndrome than in control patients, and may contribute to symptomatology in a subset of patients.

Vulvodynia

CONTEXT

Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective physical findings to explain the symptoms. The terminology and classification of vulvodynia continue to evolve, and much remains to be understood about the prevalence, pathogenesis, natural history, and management of this distressing condition.

STARTING POINT

James Aikens and colleagues showed that chronic vulval pain (vulvodynia or vulvar dysaesthesia) is associated with worse depressive symptoms (Am J Obstet Gynecol 2003; 189: 462-66). However, the increased scores for depression in this case-control study were attributed to sexual disinterest and experience of chronic pain rather than to features of depressive disorder. These results lend weight to the increasing need for better understanding of the pathogenesis of vulval pain and how to manage it appropriately. WHERE NEXT? The aetiology of vulvodynia and effectiveness of treatments need further study. Appraising the available literature, we have formulated a useful approach to patients with chronic vulval pain. There is a pressing need for further case-control studies of potential causes of vulvodynia and for randomised trials of interventions.

Immunoglobulin E antibodies to seminal fluid in women with vulvar vestibulitis syndrome: relation to onset and timing of symptoms

OBJECTIVE

Patients with vulvar vestibulitis syndrome and control subjects were tested for evidence of allergy to seminal fluid to differentiate women with a clinical diagnosis of vulvar vestibulitis syndrome into discrete categories.

STUDY DESIGN

Plasma samples from 52 women with vulvar vestibulitis syndrome and 43 control subjects were tested for immunoglobulin E antibodies to seminal fluid, total immunoglobulin E, interleukin-4, and interleukin-12 by enzyme-linked immunosorbent assay. Demographic and medical histories were obtained by questionnaire and interview.

RESULTS

Sixteen of the patients (30.8%) with vulvar vestibulitis syndrome and 2 control subjects (4.7%) tested positive for immunoglobulin E antiseminal fluid. Symptoms began after sexual intercourse in 43.8% of the women who tested immunoglobulin E positive and 11.1% of the women who tested immunoglobulin E negative (P=.02). Symptom initiation after a yeast infection was reported by 31.3% of the women who tested immunoglobulin E positive and by 2.8% of the women who tested immunoglobulin E negative (P=.008). Other symptom-initiating events were reported by 47.2% of the women who tested immunoglobulin E negative and by none of the women who tested immunoglobulin E positive (P=.0008). Fifty percent of the women who tested immunoglobulin E positive, as opposed to 22.2% of the women who tested immunoglobulin E negative, reported pain only after intercourse (P=.05). Pain at other times occurred in 50% of the women who tested immunoglobulin E positive and in 72.2% of the women who tested immunoglobulin E negative (P=.001). There was no relation between immunoglobulin E antiseminal fluid and total immunoglobulin E, interleukin-4,or interleukin-12.

CONCLUSION

A subset of women with vulvar vestibulitis syndrome are sensitized to seminal fluid, and an allergic reaction to seminal fluid may be associated with the initiation and persistence of their symptoms.

Interleukin-1beta gene polymorphism in women with vulvar vestibulitis syndrome

OBJECTIVE

The pathogenesis of vulvar vestibulitis syndrome remains unknown but may be related to a localized chronic inflammation. The relation between this syndrome and a polymorphism at position +3953 in the interleukin-1beta gene was examined. Allele 2 of this gene has been associated with increased pro-inflammatory immunity.

STUDY DESIGN

Buccal or vestibular swabs from 59 women with strictly defined vulvar vestibulitis and from 48 healthy women were tested by polymerase chain reaction for the presence of two alleles at the +3953 interleukin-1beta locus.

RESULTS

Allele 2 of the interleukin-1beta gene was identified in 27 (46%) women with vulvar vestibulitis as opposed to 12 (25%) control women (P=0.03). The interleukin-1beta 1,1 genotype was present in 36 (75%) controls as opposed to 32 (54%) vulvar vestibulitis syndrome patients (P=0.02). All subjects had been previously tested for induced interleukin-1beta production in response to bacterial lipopolysaccharide. In both patients and controls, possession of allele 2 was associated with a small but non-statistically significant increase in induced interleukin-1beta production.

CONCLUSION

Allele 2 in the interleukin-1beta gene is more common in women with vulvar vestibulitis syndrome than in other women. Susceptibility to vulvar vestibulitis syndrome might be influenced by carriage of this polymorphism.

Developments in vulvovaginal care

Clinical studies on the myriad benign diseases of the vulva and vagina have long been outnumbered by emphasis on other areas of obstetrics and gynecology. The complexity of vulvovaginal diseases emerges in the recent literature. As clinicians embrace available knowledge, women's health will improve. This review encompasses current developments in candida, bacterial vaginosis, lichen sclerosus and vulvodynia.

Differential characterization of women with vulvar vestibulitis syndrome

OBJECTIVE

We differentiated women with vulvar vestibulitis syndrome into subgroups on the basis of the time of symptom onset, a history of recurrent vulvovaginal candidiasis, and the interleukin-1 receptor antagonist gene polymorphism.

STUDY DESIGN

One hundred sixty-two consecutive patients with strictly defined vulvar vestibulitis syndrome were asked to fill out a questionnaire with the assistance of their gynecologist. A buccal sample was collected from each subject for the analysis of interleukin-1 receptor antagonist gene polymorphism; vaginal and vestibular microbial investigations were performed.

RESULTS

Symptoms began with the first act of coitus in 20.4% of patients. A history of a recurrent Candida vulvovaginal infection was reported in 42.6% of patients; 25.9% of the patients were positive for the homozygous interleukin-1 receptor antagonist 2,2 genotype. Women with primary vulvar vestibulitis syndrome differed from women with secondary vulvar vestibulitis syndrome; women with primary vulvar vestibulitis syndrome were younger at the time of the onset of the symptoms (23.8 vs 31.2 years, P <.0001) and had never been pregnant (84.8% vs 61.2%, P <.0001). Women with a history of recurrent Candida vulvovaginitis differed from the other subjects by having a higher frequency of constant vestibular pain (40.6% vs 20.4%, P =.005), a vaginal discharge (79.7% vs 45.2%, P <.0001), and dysuria (62.3% vs 29.0%, P =.0001). Women who were homozygous for interleukin-1 receptor antagonist 2,2 genotype had an earlier onset of symptoms (26 years) than did women who were allele 1 homozygotes (31.3 years, P <.05). They also had a shorter duration of symptoms (4.1 vs 5.9 years, P <.05) and a higher frequency of allergy (47.6% vs 23.4%, P =.002). Human papillomavirus in the vaginal vestibule occurred at a greater frequency in women who were homozygous for interleukin-1 receptor antagonist 2,2 genotype.

CONCLUSION

Subgroups of women with vulvar vestibulitis syndrome may be differentiated by symptomatic and genetic variables.