Jane Salodof MacNeil

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003, while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5). Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003, while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5). Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003, while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5). Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug. “If you see an HIV patient on Sustiva, please think of birth control.”

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence. If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug. “If you see an HIV patient on Sustiva, please think of birth control.”

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence. If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug. “If you see an HIV patient on Sustiva, please think of birth control.”

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence. If you don't take the drug, it doesn't work.”

PHOENIX, ARIZ. — Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours, he said.

The investigation started with animal studies. In those experiments, mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality became 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported that his hospital has instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an intensive care unit without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

PHOENIX, ARIZ. — Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours, he said.

The investigation started with animal studies. In those experiments, mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality became 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported that his hospital has instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an intensive care unit without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

PHOENIX, ARIZ. — Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours, he said.

The investigation started with animal studies. In those experiments, mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality became 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported that his hospital has instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an intensive care unit without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

HOUSTON — Strict adherence to diagnostic criteria for Behçet's disease can lead physicians to misdiagnose patients who actually have complex aphthosis, Peter J. Lynch, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Oral and genital ulcers characterize both conditions, but classic Behçet's disease typically leads to blindness and death, said Dr. Lynch, a professor emeritus at the University of California, Davis.

Though recurring and troublesome, complex aphthosis is a far more benign disorder.

“In the United States and Western Europe, complex aphthosis is usually not associated with systemic symptoms and signs. That's important, because I don't want these women labeled with Behçet's disease that they don't really have,” Dr. Lynch said.

“If they tell their primary care doctors that they have Behçet's disease or if they go online and look up Behçet's disease,” he warned, “they're going to be overwhelmed with the fact that they are going to be dead in a couple of years, and they are going to have terrible brain disease, and they are going to go blind. This is very frightening.”

Dr. Lynch traced the overlap to diagnostic criteria developed in 1990 by the International Study Group for Behçet's Disease (Lancet 1990;335:1078-80). Although other criteria have since been written to avert confusion, he said, the original ISGBD guidelines are still widely used.

If patients with complex aphthosis are to be included in the Behçet's disease spectrum, Dr. Lynch suggested the “Western” form of the disease be distinguished from the “Eastern” form, which he characterized as classic Behçet's disease.

He contrasted the two forms as follows:

▸ The Eastern form occurs along the “Silk Road” from Asia to Eastern Europe; the Western form presents in Western Europe and North America.

▸ Men outnumber women among patients with the Eastern form; women are more likely to be affected in the West.

▸ Central nervous system involvement occurs only in the Eastern form.

▸ Posterior eye inflammation often leads to blindness with the Eastern form of the condition. Anterior eye disease sometimes occurs with the Western form, but is less severe and rarely, if ever, leads to vision loss.

▸ The HLA-B51 haplotype is almost always positive with the Eastern form. People with this haplotype are much more likely to develop Behçet's disease if they live along the Silk Road (relative risk about 6.0) than in Western countries (relative risk about 1.5).

▸ Prognosis is poor in the East, good in the West.

Complex aphthosis has a nonspecific histology and is usually diagnosed by ruling out other conditions, according to Dr. Lynch. These ulcers can appear simultaneously in oral and genital locations, but are often independent of each other. “Almost always you will get a history of oral ulcers in the past, but they don't come out exactly at the same time,” he said.

Comparing aphthosis major ulcers to ordinary canker sores, Dr. Lynch said the former are larger, longer lasting, and more painful. The aphthosis ulcers also heal with some scarring and are more likely to appear on mucosa in women and on skin in men.

“There are no good age data, but in my own practice over the years I am impressed with number of very young women from age 13 to about 20 who develop this,” he said.

Dr. Lynch said most lesions respond within a few days to topical application of high potency steroids such as fluocinonide and clobetasol. He also recommended lidocaine or sucralfate for pain relief, and suggested 5 mg/cc of triamcinolone acetonide for larger ulcers and ulcers that do not respond to topical steroids.

For systemic therapy, Dr. Lynch proposed 7-10 days of treatment with systemic steroids. Dapsone, colchicine, pentoxifylline, and thalidomide can be effective for episodic treatment and prophylaxis, he said, warning against the use of thalidomide and other tumor necrosis factors in women who are of child-bearing age.

HOUSTON — Strict adherence to diagnostic criteria for Behçet's disease can lead physicians to misdiagnose patients who actually have complex aphthosis, Peter J. Lynch, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Oral and genital ulcers characterize both conditions, but classic Behçet's disease typically leads to blindness and death, said Dr. Lynch, a professor emeritus at the University of California, Davis.

Though recurring and troublesome, complex aphthosis is a far more benign disorder.

“In the United States and Western Europe, complex aphthosis is usually not associated with systemic symptoms and signs. That's important, because I don't want these women labeled with Behçet's disease that they don't really have,” Dr. Lynch said.

“If they tell their primary care doctors that they have Behçet's disease or if they go online and look up Behçet's disease,” he warned, “they're going to be overwhelmed with the fact that they are going to be dead in a couple of years, and they are going to have terrible brain disease, and they are going to go blind. This is very frightening.”

Dr. Lynch traced the overlap to diagnostic criteria developed in 1990 by the International Study Group for Behçet's Disease (Lancet 1990;335:1078-80). Although other criteria have since been written to avert confusion, he said, the original ISGBD guidelines are still widely used.

If patients with complex aphthosis are to be included in the Behçet's disease spectrum, Dr. Lynch suggested the “Western” form of the disease be distinguished from the “Eastern” form, which he characterized as classic Behçet's disease.

He contrasted the two forms as follows:

▸ The Eastern form occurs along the “Silk Road” from Asia to Eastern Europe; the Western form presents in Western Europe and North America.

▸ Men outnumber women among patients with the Eastern form; women are more likely to be affected in the West.

▸ Central nervous system involvement occurs only in the Eastern form.

▸ Posterior eye inflammation often leads to blindness with the Eastern form of the condition. Anterior eye disease sometimes occurs with the Western form, but is less severe and rarely, if ever, leads to vision loss.

▸ The HLA-B51 haplotype is almost always positive with the Eastern form. People with this haplotype are much more likely to develop Behçet's disease if they live along the Silk Road (relative risk about 6.0) than in Western countries (relative risk about 1.5).

▸ Prognosis is poor in the East, good in the West.

Complex aphthosis has a nonspecific histology and is usually diagnosed by ruling out other conditions, according to Dr. Lynch. These ulcers can appear simultaneously in oral and genital locations, but are often independent of each other. “Almost always you will get a history of oral ulcers in the past, but they don't come out exactly at the same time,” he said.

Comparing aphthosis major ulcers to ordinary canker sores, Dr. Lynch said the former are larger, longer lasting, and more painful. The aphthosis ulcers also heal with some scarring and are more likely to appear on mucosa in women and on skin in men.

“There are no good age data, but in my own practice over the years I am impressed with number of very young women from age 13 to about 20 who develop this,” he said.

Dr. Lynch said most lesions respond within a few days to topical application of high potency steroids such as fluocinonide and clobetasol. He also recommended lidocaine or sucralfate for pain relief, and suggested 5 mg/cc of triamcinolone acetonide for larger ulcers and ulcers that do not respond to topical steroids.

For systemic therapy, Dr. Lynch proposed 7-10 days of treatment with systemic steroids. Dapsone, colchicine, pentoxifylline, and thalidomide can be effective for episodic treatment and prophylaxis, he said, warning against the use of thalidomide and other tumor necrosis factors in women who are of child-bearing age.

HOUSTON — Strict adherence to diagnostic criteria for Behçet's disease can lead physicians to misdiagnose patients who actually have complex aphthosis, Peter J. Lynch, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Oral and genital ulcers characterize both conditions, but classic Behçet's disease typically leads to blindness and death, said Dr. Lynch, a professor emeritus at the University of California, Davis.

Though recurring and troublesome, complex aphthosis is a far more benign disorder.

“In the United States and Western Europe, complex aphthosis is usually not associated with systemic symptoms and signs. That's important, because I don't want these women labeled with Behçet's disease that they don't really have,” Dr. Lynch said.

“If they tell their primary care doctors that they have Behçet's disease or if they go online and look up Behçet's disease,” he warned, “they're going to be overwhelmed with the fact that they are going to be dead in a couple of years, and they are going to have terrible brain disease, and they are going to go blind. This is very frightening.”

Dr. Lynch traced the overlap to diagnostic criteria developed in 1990 by the International Study Group for Behçet's Disease (Lancet 1990;335:1078-80). Although other criteria have since been written to avert confusion, he said, the original ISGBD guidelines are still widely used.

If patients with complex aphthosis are to be included in the Behçet's disease spectrum, Dr. Lynch suggested the “Western” form of the disease be distinguished from the “Eastern” form, which he characterized as classic Behçet's disease.

He contrasted the two forms as follows:

▸ The Eastern form occurs along the “Silk Road” from Asia to Eastern Europe; the Western form presents in Western Europe and North America.

▸ Men outnumber women among patients with the Eastern form; women are more likely to be affected in the West.

▸ Central nervous system involvement occurs only in the Eastern form.

▸ Posterior eye inflammation often leads to blindness with the Eastern form of the condition. Anterior eye disease sometimes occurs with the Western form, but is less severe and rarely, if ever, leads to vision loss.

▸ The HLA-B51 haplotype is almost always positive with the Eastern form. People with this haplotype are much more likely to develop Behçet's disease if they live along the Silk Road (relative risk about 6.0) than in Western countries (relative risk about 1.5).

▸ Prognosis is poor in the East, good in the West.

Complex aphthosis has a nonspecific histology and is usually diagnosed by ruling out other conditions, according to Dr. Lynch. These ulcers can appear simultaneously in oral and genital locations, but are often independent of each other. “Almost always you will get a history of oral ulcers in the past, but they don't come out exactly at the same time,” he said.

Comparing aphthosis major ulcers to ordinary canker sores, Dr. Lynch said the former are larger, longer lasting, and more painful. The aphthosis ulcers also heal with some scarring and are more likely to appear on mucosa in women and on skin in men.

“There are no good age data, but in my own practice over the years I am impressed with number of very young women from age 13 to about 20 who develop this,” he said.

Dr. Lynch said most lesions respond within a few days to topical application of high potency steroids such as fluocinonide and clobetasol. He also recommended lidocaine or sucralfate for pain relief, and suggested 5 mg/cc of triamcinolone acetonide for larger ulcers and ulcers that do not respond to topical steroids.

For systemic therapy, Dr. Lynch proposed 7-10 days of treatment with systemic steroids. Dapsone, colchicine, pentoxifylline, and thalidomide can be effective for episodic treatment and prophylaxis, he said, warning against the use of thalidomide and other tumor necrosis factors in women who are of child-bearing age.

HOUSTON — Patient education and support are critical to effective treatment of women with recalcitrant nonneoplastic genital dermatoses, Elizabeth “Libby” Edwards, M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Often women will go to a series of physicians before the get a diagnosis. And since many skin conditions are incurable, identifying the problem can also bring the unwelcome news that it will require lifelong care, according to Dr. Edwards, chief of dermatology at the Southeast Vulvar Clinic in Charlotte, N.C.

Explaining the nature of the disease is important, as effective treatment often will control a dermatologic condition without curing it, she said. “If they think they are going to be cured, they are not going to be happy when you tell them, 'Take this three times a week for the rest of your life.'”

Dr. Edwards outlined a patient management strategy that begins with a lengthy 5- to 6-page intake questionnaire she requests new patients to complete before their first visit. The questionnaire “is more for their therapy than my evaluation,” Dr. Edwards said. Without taking up office time, the questionnaire allows the patient to tell the physician everything she has gone through in trying to figure out what is wrong.

Once she makes her diagnosis, Dr. Edwards gives the women preprinted handouts (samples available at www.libbyedwardsmd.com

Dr. Edwards said she also uses Polaroid photographs taken on the examining table. She sends one home with the patient as a guide to where to place medication and staples the other in the patient's chart for future reference. “They walk out much less confused,” she said.

Dr. Edwards' patients also are encouraged to go for individual and couples counseling because genital skin conditions often lead to avoidance of sexual activity. “These women almost all have psychosexual issues,” she said, emphasizing that these issues are typically a result rather than a cause of the medical condition.

Other recommendations include stopping irritants such as overwashing, cream medications, and panty liners. Dr. Edwards suggested that petrolatum (petroleum jelly) could be used to soothe irritation without causing contact dermatitis.

Ointments and oral medications are preferred because creams often can sting, Dr. Edwards explained. If the patient complains about feeling itchy at night, she recommended nighttime sedation to prevent scratching. “There are no intrinsic anti-itching medications,” Dr. Edwards said. The alternatives are treating the cause of the itch, applying a topical anesthetic, or making the patient too sleepy to itch.

As treatment with corticosteroids will often bring quick relief, Dr. Edwards said patients should be forewarned against stopping treatment and tapering off too soon. Tiny amounts were recommended, and she said patients taking an ultrapotent steroid every day should be reevaluated on a monthly basis.

Once the disease has stabilized, Dr. Edwards said most patients can tolerate medication 3 days per week as a long-term treatment. If the patient is doing well, switching from ointment to a less greasy cream is also an option.

However, if the patient does not respond positively, Dr. Edwards said the physician should revaluate for possible infection.

HOUSTON — Patient education and support are critical to effective treatment of women with recalcitrant nonneoplastic genital dermatoses, Elizabeth “Libby” Edwards, M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Often women will go to a series of physicians before the get a diagnosis. And since many skin conditions are incurable, identifying the problem can also bring the unwelcome news that it will require lifelong care, according to Dr. Edwards, chief of dermatology at the Southeast Vulvar Clinic in Charlotte, N.C.

Explaining the nature of the disease is important, as effective treatment often will control a dermatologic condition without curing it, she said. “If they think they are going to be cured, they are not going to be happy when you tell them, 'Take this three times a week for the rest of your life.'”

Dr. Edwards outlined a patient management strategy that begins with a lengthy 5- to 6-page intake questionnaire she requests new patients to complete before their first visit. The questionnaire “is more for their therapy than my evaluation,” Dr. Edwards said. Without taking up office time, the questionnaire allows the patient to tell the physician everything she has gone through in trying to figure out what is wrong.

Once she makes her diagnosis, Dr. Edwards gives the women preprinted handouts (samples available at www.libbyedwardsmd.com

Dr. Edwards said she also uses Polaroid photographs taken on the examining table. She sends one home with the patient as a guide to where to place medication and staples the other in the patient's chart for future reference. “They walk out much less confused,” she said.

Dr. Edwards' patients also are encouraged to go for individual and couples counseling because genital skin conditions often lead to avoidance of sexual activity. “These women almost all have psychosexual issues,” she said, emphasizing that these issues are typically a result rather than a cause of the medical condition.

Other recommendations include stopping irritants such as overwashing, cream medications, and panty liners. Dr. Edwards suggested that petrolatum (petroleum jelly) could be used to soothe irritation without causing contact dermatitis.

Ointments and oral medications are preferred because creams often can sting, Dr. Edwards explained. If the patient complains about feeling itchy at night, she recommended nighttime sedation to prevent scratching. “There are no intrinsic anti-itching medications,” Dr. Edwards said. The alternatives are treating the cause of the itch, applying a topical anesthetic, or making the patient too sleepy to itch.

As treatment with corticosteroids will often bring quick relief, Dr. Edwards said patients should be forewarned against stopping treatment and tapering off too soon. Tiny amounts were recommended, and she said patients taking an ultrapotent steroid every day should be reevaluated on a monthly basis.

Once the disease has stabilized, Dr. Edwards said most patients can tolerate medication 3 days per week as a long-term treatment. If the patient is doing well, switching from ointment to a less greasy cream is also an option.

However, if the patient does not respond positively, Dr. Edwards said the physician should revaluate for possible infection.

HOUSTON — Patient education and support are critical to effective treatment of women with recalcitrant nonneoplastic genital dermatoses, Elizabeth “Libby” Edwards, M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Often women will go to a series of physicians before the get a diagnosis. And since many skin conditions are incurable, identifying the problem can also bring the unwelcome news that it will require lifelong care, according to Dr. Edwards, chief of dermatology at the Southeast Vulvar Clinic in Charlotte, N.C.

Explaining the nature of the disease is important, as effective treatment often will control a dermatologic condition without curing it, she said. “If they think they are going to be cured, they are not going to be happy when you tell them, 'Take this three times a week for the rest of your life.'”

Dr. Edwards outlined a patient management strategy that begins with a lengthy 5- to 6-page intake questionnaire she requests new patients to complete before their first visit. The questionnaire “is more for their therapy than my evaluation,” Dr. Edwards said. Without taking up office time, the questionnaire allows the patient to tell the physician everything she has gone through in trying to figure out what is wrong.

Once she makes her diagnosis, Dr. Edwards gives the women preprinted handouts (samples available at www.libbyedwardsmd.com

Dr. Edwards said she also uses Polaroid photographs taken on the examining table. She sends one home with the patient as a guide to where to place medication and staples the other in the patient's chart for future reference. “They walk out much less confused,” she said.

Dr. Edwards' patients also are encouraged to go for individual and couples counseling because genital skin conditions often lead to avoidance of sexual activity. “These women almost all have psychosexual issues,” she said, emphasizing that these issues are typically a result rather than a cause of the medical condition.

Other recommendations include stopping irritants such as overwashing, cream medications, and panty liners. Dr. Edwards suggested that petrolatum (petroleum jelly) could be used to soothe irritation without causing contact dermatitis.

Ointments and oral medications are preferred because creams often can sting, Dr. Edwards explained. If the patient complains about feeling itchy at night, she recommended nighttime sedation to prevent scratching. “There are no intrinsic anti-itching medications,” Dr. Edwards said. The alternatives are treating the cause of the itch, applying a topical anesthetic, or making the patient too sleepy to itch.

As treatment with corticosteroids will often bring quick relief, Dr. Edwards said patients should be forewarned against stopping treatment and tapering off too soon. Tiny amounts were recommended, and she said patients taking an ultrapotent steroid every day should be reevaluated on a monthly basis.

Once the disease has stabilized, Dr. Edwards said most patients can tolerate medication 3 days per week as a long-term treatment. If the patient is doing well, switching from ointment to a less greasy cream is also an option.

However, if the patient does not respond positively, Dr. Edwards said the physician should revaluate for possible infection.

SANTA FE, N.M. — U.S. clinicians ought to tell hysterectomy candidates they have the option of leaving the cervix intact—and should give full information about the controversial alternative so patients can make informed choices, Craig A. Winkel, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

There is a broad disconnect between what women read about supracervical hysterectomy on the Internet and the hard data in the scientific literature, according to Dr. Winkel of Georgetown University School of Nursing, Washington. Claims of better preservation of sexual, bladder, and bowel function with supracervical hysterectomy are contradicted by randomized, controlled trials, he said.

Adding to the confusion, nearly two-thirds of area physicians surveyed by his group at Georgetown said they neither offer their patients a choice nor counsel them about supracervical hysterectomy as an option, he said. Fear of cervical cancer apparently was not a factor; 81% of the physicians said the risk was negligible (Obstet. Gynecol. 2003;102:301-5).

“All women who are hysterectomy candidates should be counseled and given the choice. The data say it is easier for you to do the supracervical [procedure], and you may reduce the complications,” Dr. Winkel said, advocating full disclosure, although he noted that more trials are needed before the evidence can be considered conclusive.

Supracervical hysterectomy is widely done in Europe and was standard practice in the United States until the mid-1940s, according to Dr. Winkel, in a review of the data to date. He said interest in this country has been revived by a recommendation from the American College of Obstetricians and Gynecologists calling for a 30% reduction in abdominal hysterectomies.

In 1983, a retrospective study reported that coital frequency, orgasm, and libido all decreased while dyspareunia increased in women asked to compare their sexual functioning before and after removal of the cervix (Acta. Obstet. Gynecol. Scand. 1983;62:141-5). Dr. Winkel quoted the investigator as theorizing that leaving the cervix intact better preserves Frankenhäuser's ganglion of autonomic nerves.

According to Dr. Winkel, an anatomy study subsequently ruled out this theory, noting that simple hysterectomy causes “minimal disruption of nerves or ganglia” (Cancer 2000;89:834-41).

Since then, Dr. Winkel said two randomized controlled trials (N. Engl. J. Med. 2002; 347:1318-25 and BJOG 2003;110:1088-98) and a prospective study (BMJ 2003;327:774-8) have shown no difference in sexual satisfaction. The study published in the New England Journal of Medicine included 279 patients.

The impact of supracervical hysterectomy on morbidity is less clear, however. Complications were significantly less during and after discharge with supracervical hysterectomy, compared with total hysterectomy in the New England Journal of Medicine study. Cyclic vaginal bleeding and cervical prolapse were reported at 12 months in 7% and 2%, respectively, of supracervical patients, but none who had undergone total hysterectomy. Conversely, persistent pain was higher in the total hysterectomy group (6.4%) than in the supracervical hysterectomy group (2.8%).

Dr. Winkel also cited a prospective trial that found fewer complications, (Obstet. Gynecol. 2003;102:453-62) compared with total hysterectomy, and an observational study concluding that classic intrafascial supracervical hysterectomy has a lower complication rate than laparoscopic hysterectomy (J. Am. Assoc. Gynecol. Laparosc. 1998;3:253-60). A third study, however, found increases in cyclic bleeding, dyspareunia, and trachelectomy with laparoscopic supracervical hysterectomy (BJOG 2001;108:1017-20).

“Supracervical hysterectomy is easier than removing the cervix. The data suggest supracervical hysterectomy may be safer.”

SANTA FE, N.M. — U.S. clinicians ought to tell hysterectomy candidates they have the option of leaving the cervix intact—and should give full information about the controversial alternative so patients can make informed choices, Craig A. Winkel, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

There is a broad disconnect between what women read about supracervical hysterectomy on the Internet and the hard data in the scientific literature, according to Dr. Winkel of Georgetown University School of Nursing, Washington. Claims of better preservation of sexual, bladder, and bowel function with supracervical hysterectomy are contradicted by randomized, controlled trials, he said.

Adding to the confusion, nearly two-thirds of area physicians surveyed by his group at Georgetown said they neither offer their patients a choice nor counsel them about supracervical hysterectomy as an option, he said. Fear of cervical cancer apparently was not a factor; 81% of the physicians said the risk was negligible (Obstet. Gynecol. 2003;102:301-5).

“All women who are hysterectomy candidates should be counseled and given the choice. The data say it is easier for you to do the supracervical [procedure], and you may reduce the complications,” Dr. Winkel said, advocating full disclosure, although he noted that more trials are needed before the evidence can be considered conclusive.

Supracervical hysterectomy is widely done in Europe and was standard practice in the United States until the mid-1940s, according to Dr. Winkel, in a review of the data to date. He said interest in this country has been revived by a recommendation from the American College of Obstetricians and Gynecologists calling for a 30% reduction in abdominal hysterectomies.

In 1983, a retrospective study reported that coital frequency, orgasm, and libido all decreased while dyspareunia increased in women asked to compare their sexual functioning before and after removal of the cervix (Acta. Obstet. Gynecol. Scand. 1983;62:141-5). Dr. Winkel quoted the investigator as theorizing that leaving the cervix intact better preserves Frankenhäuser's ganglion of autonomic nerves.

According to Dr. Winkel, an anatomy study subsequently ruled out this theory, noting that simple hysterectomy causes “minimal disruption of nerves or ganglia” (Cancer 2000;89:834-41).

Since then, Dr. Winkel said two randomized controlled trials (N. Engl. J. Med. 2002; 347:1318-25 and BJOG 2003;110:1088-98) and a prospective study (BMJ 2003;327:774-8) have shown no difference in sexual satisfaction. The study published in the New England Journal of Medicine included 279 patients.

The impact of supracervical hysterectomy on morbidity is less clear, however. Complications were significantly less during and after discharge with supracervical hysterectomy, compared with total hysterectomy in the New England Journal of Medicine study. Cyclic vaginal bleeding and cervical prolapse were reported at 12 months in 7% and 2%, respectively, of supracervical patients, but none who had undergone total hysterectomy. Conversely, persistent pain was higher in the total hysterectomy group (6.4%) than in the supracervical hysterectomy group (2.8%).

Dr. Winkel also cited a prospective trial that found fewer complications, (Obstet. Gynecol. 2003;102:453-62) compared with total hysterectomy, and an observational study concluding that classic intrafascial supracervical hysterectomy has a lower complication rate than laparoscopic hysterectomy (J. Am. Assoc. Gynecol. Laparosc. 1998;3:253-60). A third study, however, found increases in cyclic bleeding, dyspareunia, and trachelectomy with laparoscopic supracervical hysterectomy (BJOG 2001;108:1017-20).

“Supracervical hysterectomy is easier than removing the cervix. The data suggest supracervical hysterectomy may be safer.”

SANTA FE, N.M. — U.S. clinicians ought to tell hysterectomy candidates they have the option of leaving the cervix intact—and should give full information about the controversial alternative so patients can make informed choices, Craig A. Winkel, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

There is a broad disconnect between what women read about supracervical hysterectomy on the Internet and the hard data in the scientific literature, according to Dr. Winkel of Georgetown University School of Nursing, Washington. Claims of better preservation of sexual, bladder, and bowel function with supracervical hysterectomy are contradicted by randomized, controlled trials, he said.

Adding to the confusion, nearly two-thirds of area physicians surveyed by his group at Georgetown said they neither offer their patients a choice nor counsel them about supracervical hysterectomy as an option, he said. Fear of cervical cancer apparently was not a factor; 81% of the physicians said the risk was negligible (Obstet. Gynecol. 2003;102:301-5).

“All women who are hysterectomy candidates should be counseled and given the choice. The data say it is easier for you to do the supracervical [procedure], and you may reduce the complications,” Dr. Winkel said, advocating full disclosure, although he noted that more trials are needed before the evidence can be considered conclusive.

Supracervical hysterectomy is widely done in Europe and was standard practice in the United States until the mid-1940s, according to Dr. Winkel, in a review of the data to date. He said interest in this country has been revived by a recommendation from the American College of Obstetricians and Gynecologists calling for a 30% reduction in abdominal hysterectomies.

In 1983, a retrospective study reported that coital frequency, orgasm, and libido all decreased while dyspareunia increased in women asked to compare their sexual functioning before and after removal of the cervix (Acta. Obstet. Gynecol. Scand. 1983;62:141-5). Dr. Winkel quoted the investigator as theorizing that leaving the cervix intact better preserves Frankenhäuser's ganglion of autonomic nerves.

According to Dr. Winkel, an anatomy study subsequently ruled out this theory, noting that simple hysterectomy causes “minimal disruption of nerves or ganglia” (Cancer 2000;89:834-41).

Since then, Dr. Winkel said two randomized controlled trials (N. Engl. J. Med. 2002; 347:1318-25 and BJOG 2003;110:1088-98) and a prospective study (BMJ 2003;327:774-8) have shown no difference in sexual satisfaction. The study published in the New England Journal of Medicine included 279 patients.

The impact of supracervical hysterectomy on morbidity is less clear, however. Complications were significantly less during and after discharge with supracervical hysterectomy, compared with total hysterectomy in the New England Journal of Medicine study. Cyclic vaginal bleeding and cervical prolapse were reported at 12 months in 7% and 2%, respectively, of supracervical patients, but none who had undergone total hysterectomy. Conversely, persistent pain was higher in the total hysterectomy group (6.4%) than in the supracervical hysterectomy group (2.8%).

Dr. Winkel also cited a prospective trial that found fewer complications, (Obstet. Gynecol. 2003;102:453-62) compared with total hysterectomy, and an observational study concluding that classic intrafascial supracervical hysterectomy has a lower complication rate than laparoscopic hysterectomy (J. Am. Assoc. Gynecol. Laparosc. 1998;3:253-60). A third study, however, found increases in cyclic bleeding, dyspareunia, and trachelectomy with laparoscopic supracervical hysterectomy (BJOG 2001;108:1017-20).

“Supracervical hysterectomy is easier than removing the cervix. The data suggest supracervical hysterectomy may be safer.”

HOUSTON — Telephone consultations for vaginitis often result in misdiagnosis, Dale Brown Jr., M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Patients think it is a drag to come in to be evaluated, and many health care professionals think it is a drag to have to treat vaginitis all the time,” said Dr. Brown, chairman of clinical affairs in the obstetrics and gynecology department at Baylor.

Nonetheless, thorough office examinations are necessary, even for what appear to be repeated fungal infections, according to Dr. Brown. He maintained that symptoms are often misleading, and studies have found relatively few women can accurately self-diagnose vulvovaginal candidiasis.

“Patients are spending a lot of money over the counter and then they have to come in to be treated again. They don't know what they are treating,” Dr. Brown said, contending that availability of over-the-counter antifungal treatments for candidiasis has not lived up to expectations of reduced health care costs. Instead, he said, many women are seeking a physician's help only after trying two or three different medications that did not relieve their symptoms.

Candida albicans was confirmed in only 33% of cases for which over-the-counter medications were purchased in one report cited by Dr. Brown (J. Fam. Pract. 1996;42:595-600).

He noted that women with a history of diagnosed fungal infections were even more likely to misdiagnose a repeat infection.

In another study at a vaginitis referral center, he said only 28% of cases of candidiasis were clinically confirmed (Obstet. Gynecol. 1997;90:50-3).

A third investigation cited by Dr. Brown involved the collection of vaginal swabs every 4 months from 1,248 women. He said the study, presented at a meeting of the Infectious Diseases Society for Obstetrics and Gynecology in 2002, found 24% of women who were never colonized by yeast used antifungal drugs at least once.

At least half the women who are diagnosed with candidiasis actually have another condition, according to Dr. Brown. Although frequently suspected, candidiasis accounts for only 20%-25% of vaginitis; bacteria are responsible for 40%-50% of cases and trichomoniasis for 15%-20%.

Dr. Brown urged consideration of other noninfectious causes and less common infections. He gave a long list of possible diagnoses that included atrophic vaginitis, a foreign body, allergic hypersensitivity and contact dermatitis, trauma, desquamative inflammatory vaginitis, erosive lichen planus, lactobacilli vaginosis, cytolytic vaginosis, streptococcal group A infection, ulcerative vaginitis with Staphylococcus aureus, and idiopathic ulceration associated with human immunodeficiency virus.

When examining women for vaginitis, physicians should have patients use a magnifying glass to identify the exact location of the itch.

He recommended collecting a specimen from the lateral midsection of the vagina and looking for systemic diseases that can present as a vulvovaginal symptom. He singled out erythrasma and tinea cruris as two conditions that can be mistaken for candidiasis.

“Most common vaginitis is not hard to treat, but too often we make a diagnosis that is not the correct diagnosis and we get failure of our treatment,” he said.

HOUSTON — Telephone consultations for vaginitis often result in misdiagnosis, Dale Brown Jr., M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Patients think it is a drag to come in to be evaluated, and many health care professionals think it is a drag to have to treat vaginitis all the time,” said Dr. Brown, chairman of clinical affairs in the obstetrics and gynecology department at Baylor.

Nonetheless, thorough office examinations are necessary, even for what appear to be repeated fungal infections, according to Dr. Brown. He maintained that symptoms are often misleading, and studies have found relatively few women can accurately self-diagnose vulvovaginal candidiasis.

“Patients are spending a lot of money over the counter and then they have to come in to be treated again. They don't know what they are treating,” Dr. Brown said, contending that availability of over-the-counter antifungal treatments for candidiasis has not lived up to expectations of reduced health care costs. Instead, he said, many women are seeking a physician's help only after trying two or three different medications that did not relieve their symptoms.

Candida albicans was confirmed in only 33% of cases for which over-the-counter medications were purchased in one report cited by Dr. Brown (J. Fam. Pract. 1996;42:595-600).

He noted that women with a history of diagnosed fungal infections were even more likely to misdiagnose a repeat infection.

In another study at a vaginitis referral center, he said only 28% of cases of candidiasis were clinically confirmed (Obstet. Gynecol. 1997;90:50-3).

A third investigation cited by Dr. Brown involved the collection of vaginal swabs every 4 months from 1,248 women. He said the study, presented at a meeting of the Infectious Diseases Society for Obstetrics and Gynecology in 2002, found 24% of women who were never colonized by yeast used antifungal drugs at least once.

At least half the women who are diagnosed with candidiasis actually have another condition, according to Dr. Brown. Although frequently suspected, candidiasis accounts for only 20%-25% of vaginitis; bacteria are responsible for 40%-50% of cases and trichomoniasis for 15%-20%.

Dr. Brown urged consideration of other noninfectious causes and less common infections. He gave a long list of possible diagnoses that included atrophic vaginitis, a foreign body, allergic hypersensitivity and contact dermatitis, trauma, desquamative inflammatory vaginitis, erosive lichen planus, lactobacilli vaginosis, cytolytic vaginosis, streptococcal group A infection, ulcerative vaginitis with Staphylococcus aureus, and idiopathic ulceration associated with human immunodeficiency virus.

When examining women for vaginitis, physicians should have patients use a magnifying glass to identify the exact location of the itch.

He recommended collecting a specimen from the lateral midsection of the vagina and looking for systemic diseases that can present as a vulvovaginal symptom. He singled out erythrasma and tinea cruris as two conditions that can be mistaken for candidiasis.

“Most common vaginitis is not hard to treat, but too often we make a diagnosis that is not the correct diagnosis and we get failure of our treatment,” he said.

HOUSTON — Telephone consultations for vaginitis often result in misdiagnosis, Dale Brown Jr., M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Patients think it is a drag to come in to be evaluated, and many health care professionals think it is a drag to have to treat vaginitis all the time,” said Dr. Brown, chairman of clinical affairs in the obstetrics and gynecology department at Baylor.

Nonetheless, thorough office examinations are necessary, even for what appear to be repeated fungal infections, according to Dr. Brown. He maintained that symptoms are often misleading, and studies have found relatively few women can accurately self-diagnose vulvovaginal candidiasis.

“Patients are spending a lot of money over the counter and then they have to come in to be treated again. They don't know what they are treating,” Dr. Brown said, contending that availability of over-the-counter antifungal treatments for candidiasis has not lived up to expectations of reduced health care costs. Instead, he said, many women are seeking a physician's help only after trying two or three different medications that did not relieve their symptoms.

Candida albicans was confirmed in only 33% of cases for which over-the-counter medications were purchased in one report cited by Dr. Brown (J. Fam. Pract. 1996;42:595-600).

He noted that women with a history of diagnosed fungal infections were even more likely to misdiagnose a repeat infection.

In another study at a vaginitis referral center, he said only 28% of cases of candidiasis were clinically confirmed (Obstet. Gynecol. 1997;90:50-3).

A third investigation cited by Dr. Brown involved the collection of vaginal swabs every 4 months from 1,248 women. He said the study, presented at a meeting of the Infectious Diseases Society for Obstetrics and Gynecology in 2002, found 24% of women who were never colonized by yeast used antifungal drugs at least once.

At least half the women who are diagnosed with candidiasis actually have another condition, according to Dr. Brown. Although frequently suspected, candidiasis accounts for only 20%-25% of vaginitis; bacteria are responsible for 40%-50% of cases and trichomoniasis for 15%-20%.

Dr. Brown urged consideration of other noninfectious causes and less common infections. He gave a long list of possible diagnoses that included atrophic vaginitis, a foreign body, allergic hypersensitivity and contact dermatitis, trauma, desquamative inflammatory vaginitis, erosive lichen planus, lactobacilli vaginosis, cytolytic vaginosis, streptococcal group A infection, ulcerative vaginitis with Staphylococcus aureus, and idiopathic ulceration associated with human immunodeficiency virus.

When examining women for vaginitis, physicians should have patients use a magnifying glass to identify the exact location of the itch.

He recommended collecting a specimen from the lateral midsection of the vagina and looking for systemic diseases that can present as a vulvovaginal symptom. He singled out erythrasma and tinea cruris as two conditions that can be mistaken for candidiasis.

“Most common vaginitis is not hard to treat, but too often we make a diagnosis that is not the correct diagnosis and we get failure of our treatment,” he said.

HOUSTON — A new guideline for the diagnosis and treatment of vulvodynia offers multiple treatment options, including experimental and complementary therapies, for the controversial disorder.

“We have oceans of lotions, potions, and notions out there for vulvodynia. There is not going to be one simple cure,” Hope K. Haefner, M.D., the lead author of a paper detailing the guideline, said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

What is clear, she said, is, “We have to do a lot more than say, 'Love burns.'”

Dr. Haefner, director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, recruited a panel of vulvar disease experts to draft the guideline at the request of the American Society for Colposcopy and Cervical Pathology (ASCCP). The guideline is published in the society's journal and can be accessed at www.jlgtd.com

Women's physicians are increasingly aware of vulvodynia but need to start treatment early, according to Dr. Haefner. “The longer a patient has the pain, the less likely we are going to be able to cure” her, she said.

The guideline uses terminology the International Society for the Study of Vulvovaginal Disease (ISSVD) recently adopted for vulvodynia, which has had multiple names, including vulvar vestibulitis syndrome and vulvar dysesthesia. The ISSVD defined vulvodynia as “vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder.”

Symptoms are not necessarily caused by touch or pressure to the vulva, such as with intercourse or bicycle riding, but these activities often exacerbate the symptoms.

The guideline also classified vulvodynia according to whether pain is generalized or localized. (Dr. Haefner cited vestibulodynia, clitorodynia, and hemivulvodynia as examples of localized pain.)

The ASCCP guideline recommends cotton swab testing along with the taking of a complete medical history for diagnosis. Health care providers should use the swab to test various locations of the vulva, including the labia majora, the labia minora, the interlabial sulci, and the vestibule at the clock positions of 2:00, 4:00, 6:00, 8:00, and 10:00. The degree of pain at each location should be recorded. Vaginal culture should be done to rule out conditions such as yeast infection.

Treatment recommendations start with gentle care for the vulva. This includes wearing cotton underwear and nonirritating menstrual pads, avoiding irritants, and using mild soap. Patients are urged to pat the vulva dry. Other suggestions include lubrication during intercourse, cold packs for irritation, and rinsing and drying the vulva after urination.

The guideline lists the following topical medications as useful for vulvar pain but with caveats and suggests that stopping all treatments may bring relief to some women who are using multiple topical medications:

▸ Lidocaine ointment 5% (various forms) is the most commonly prescribed topical treatment.

▸ Plain petroleum jelly can help symptoms.

▸ Estrogen has had variable results; however, Dr. Haefner questions how it works, given that many vulvodynia patients have low estrogen-receptor expression.

▸ Capsaicin is cited for neuropathic pain, but again, Dr. Haefner was skeptical that it works because this agent is an irritant.

▸ Nitroglycerine in one study improved vulvar pain and dyspareunia temporarily but caused headaches.

▸ Baclofen 2% (Lioresal) and amitriptyline 2% in a water-washable base can soothe point tenderness and vaginismus.

Topical corticosteroids, testosterone, and antifungal medications have not benefited vulvodynia patients, according to the guideline. Dr. Haefner also warned against use of benzocaine in these patients, which she said could cause rebound vasodilation and pain.

Oral medications for vulvodynia generally fall into two classes: antidepressants and anticonvulsants. If these are used, the guideline warns health care providers to check for drug interactions with other medications the patient is taking.

Dr. Haefner said tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline have had a 65%-70% response rate in multiple studies. When they are prescribed for pain management, smaller doses are recommended than for depression. Selective serotonin reuptake inhibitors such as venlafaxine are another option.

Dr. Haefner said she has also used duloxetine (Cymbalta), but a controlled study is needed to assess its efficacy in vulvodynia patients. The guideline also cites the use of anticonvulsants gabapentin (Neurontin) and carbamazepine.

Other guideline recommendations include biofeedback and physical therapy, intralesional injections in patients with localized pain, and surgery as a last resort in patients with vestibulodynia. Surgery is also an option in rare cases of pudendal nerve entrapment.

“The one time I do surgery without trying the other treatments discussed is when they have a lot of redundant tissue that is painful and tears with intercourse. Then I just resect that tissue,” Dr. Haefner said.

The guideline notes without judgment that many women use complementary and alternative therapies “before, during, and after seeking conventional medical diagnosis and treatment for their vulvar pain symptoms.” These include acupuncture, calcium citrate, low-oxalate diets, oatmeal water and saltwater baths, and, according to Dr. Haefner, hypnosis and botulinum toxin (Botox) injections.

“There are a lot of different things out there that need to be duplicated in different studies,” she said, describing low-oxalate diets, in particular, as controversial.

Finally, the guideline says vulvodynia is not a psychopathologic condition, but patients should receive emotional and psychological support during treatment.

For more information, contact the International Society for the Study of Vulvovaginal Disease by calling 704-814-9493 or go towww.issvd.org

Experts Dispute Psychosexual Factors

The new vulvodynia guideline rejects the assumption that vulvar pain without a clinically identifiable cause is all in a woman's head but notes that “sex therapy, couples counseling, psychotherapy, or a combination thereof” can be very helpful to patients.

“For years, there were people who thought it was a psychosomatic illness, and there are some people who still do believe that,” Dr. Haefner said. “I don't think it is. However, psychologically, many of our patients are depressed.”

The first description of vulvodynia in an 1880 medical textbook called the condition “hyperaesthesia of the vulva,” she said.

Although it has become more prevalent following recent media attention to women's accounts of the disorder, vulvodynia affects far more women and has been around far longer than has been recognized, she said.

Just what causes vulvodynia is still unclear. Dr. Haefner cited current thinking that the condition is neurologic or inflammatory in origin. (She leans toward neurologic but acknowledged it could be both.) Although she discounted sexual abuse as no more common in vulvodynia patients than in the general population, she said that it could be a factor in individual cases.

Elizabeth “Libby” Edwards, M.D., chief of dermatology of the Southeast Vulvar Clinic in Charlotte, N.C., said that many vulvodynia patients have psychosexual issues but also described them as a result of the illness.

“Depression, anxiety, psychosexual dysfunction is rarely, if ever, a cause of vulvodynia. I don't discount the possibility that it may occasionally happen,” said Dr. Edwards, also of the University of North Carolina at Chapel Hill.

Dr. Edwards, a dermatologist who specializes in vulvar disorders, said she encourages patients to go for counseling, but most won't go. She said her message is “not 'You're crazy, and that makes you hurt,' but 'You hurt, and that will make you crazy.'”

Sexual abuse is a major underlying factor for vulvodynia patients, according to Esperanza McKay, M.D., a biofeedback clinician at the Pain Management Center in Houston. That should not cause anyone to underestimate the women's suffering, she advised.

“Their pain is really very real,” she said. “The first thing I do is listen to them. You will be amazed at how many have been sexually abused.”

Dr. McKay recommended waiting 3 or 4 months until a treatment begins to succeed before bringing up counseling. Many patients do not trust psychiatry and need to develop trust in the clinician before they will agree to go for counseling, she said.

Peter J. Lynch, M.D., a professor emeritus at the University of California, Davis, also advocated psychiatric help, warning that extreme cases can be the result of severe sexual abuse. “I happen to believe that psychosexual issues are an important cause of vulvodynia,” he said.

HOUSTON — A new guideline for the diagnosis and treatment of vulvodynia offers multiple treatment options, including experimental and complementary therapies, for the controversial disorder.

“We have oceans of lotions, potions, and notions out there for vulvodynia. There is not going to be one simple cure,” Hope K. Haefner, M.D., the lead author of a paper detailing the guideline, said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

What is clear, she said, is, “We have to do a lot more than say, 'Love burns.'”

Dr. Haefner, director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, recruited a panel of vulvar disease experts to draft the guideline at the request of the American Society for Colposcopy and Cervical Pathology (ASCCP). The guideline is published in the society's journal and can be accessed at www.jlgtd.com

Women's physicians are increasingly aware of vulvodynia but need to start treatment early, according to Dr. Haefner. “The longer a patient has the pain, the less likely we are going to be able to cure” her, she said.

The guideline uses terminology the International Society for the Study of Vulvovaginal Disease (ISSVD) recently adopted for vulvodynia, which has had multiple names, including vulvar vestibulitis syndrome and vulvar dysesthesia. The ISSVD defined vulvodynia as “vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder.”

Symptoms are not necessarily caused by touch or pressure to the vulva, such as with intercourse or bicycle riding, but these activities often exacerbate the symptoms.

The guideline also classified vulvodynia according to whether pain is generalized or localized. (Dr. Haefner cited vestibulodynia, clitorodynia, and hemivulvodynia as examples of localized pain.)

The ASCCP guideline recommends cotton swab testing along with the taking of a complete medical history for diagnosis. Health care providers should use the swab to test various locations of the vulva, including the labia majora, the labia minora, the interlabial sulci, and the vestibule at the clock positions of 2:00, 4:00, 6:00, 8:00, and 10:00. The degree of pain at each location should be recorded. Vaginal culture should be done to rule out conditions such as yeast infection.

Treatment recommendations start with gentle care for the vulva. This includes wearing cotton underwear and nonirritating menstrual pads, avoiding irritants, and using mild soap. Patients are urged to pat the vulva dry. Other suggestions include lubrication during intercourse, cold packs for irritation, and rinsing and drying the vulva after urination.

The guideline lists the following topical medications as useful for vulvar pain but with caveats and suggests that stopping all treatments may bring relief to some women who are using multiple topical medications:

▸ Lidocaine ointment 5% (various forms) is the most commonly prescribed topical treatment.

▸ Plain petroleum jelly can help symptoms.

▸ Estrogen has had variable results; however, Dr. Haefner questions how it works, given that many vulvodynia patients have low estrogen-receptor expression.

▸ Capsaicin is cited for neuropathic pain, but again, Dr. Haefner was skeptical that it works because this agent is an irritant.

▸ Nitroglycerine in one study improved vulvar pain and dyspareunia temporarily but caused headaches.

▸ Baclofen 2% (Lioresal) and amitriptyline 2% in a water-washable base can soothe point tenderness and vaginismus.

Topical corticosteroids, testosterone, and antifungal medications have not benefited vulvodynia patients, according to the guideline. Dr. Haefner also warned against use of benzocaine in these patients, which she said could cause rebound vasodilation and pain.

Oral medications for vulvodynia generally fall into two classes: antidepressants and anticonvulsants. If these are used, the guideline warns health care providers to check for drug interactions with other medications the patient is taking.

Dr. Haefner said tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline have had a 65%-70% response rate in multiple studies. When they are prescribed for pain management, smaller doses are recommended than for depression. Selective serotonin reuptake inhibitors such as venlafaxine are another option.

Dr. Haefner said she has also used duloxetine (Cymbalta), but a controlled study is needed to assess its efficacy in vulvodynia patients. The guideline also cites the use of anticonvulsants gabapentin (Neurontin) and carbamazepine.

Other guideline recommendations include biofeedback and physical therapy, intralesional injections in patients with localized pain, and surgery as a last resort in patients with vestibulodynia. Surgery is also an option in rare cases of pudendal nerve entrapment.

“The one time I do surgery without trying the other treatments discussed is when they have a lot of redundant tissue that is painful and tears with intercourse. Then I just resect that tissue,” Dr. Haefner said.

The guideline notes without judgment that many women use complementary and alternative therapies “before, during, and after seeking conventional medical diagnosis and treatment for their vulvar pain symptoms.” These include acupuncture, calcium citrate, low-oxalate diets, oatmeal water and saltwater baths, and, according to Dr. Haefner, hypnosis and botulinum toxin (Botox) injections.

“There are a lot of different things out there that need to be duplicated in different studies,” she said, describing low-oxalate diets, in particular, as controversial.

Finally, the guideline says vulvodynia is not a psychopathologic condition, but patients should receive emotional and psychological support during treatment.

For more information, contact the International Society for the Study of Vulvovaginal Disease by calling 704-814-9493 or go towww.issvd.org

Experts Dispute Psychosexual Factors

The new vulvodynia guideline rejects the assumption that vulvar pain without a clinically identifiable cause is all in a woman's head but notes that “sex therapy, couples counseling, psychotherapy, or a combination thereof” can be very helpful to patients.

“For years, there were people who thought it was a psychosomatic illness, and there are some people who still do believe that,” Dr. Haefner said. “I don't think it is. However, psychologically, many of our patients are depressed.”

The first description of vulvodynia in an 1880 medical textbook called the condition “hyperaesthesia of the vulva,” she said.

Although it has become more prevalent following recent media attention to women's accounts of the disorder, vulvodynia affects far more women and has been around far longer than has been recognized, she said.

Just what causes vulvodynia is still unclear. Dr. Haefner cited current thinking that the condition is neurologic or inflammatory in origin. (She leans toward neurologic but acknowledged it could be both.) Although she discounted sexual abuse as no more common in vulvodynia patients than in the general population, she said that it could be a factor in individual cases.

Elizabeth “Libby” Edwards, M.D., chief of dermatology of the Southeast Vulvar Clinic in Charlotte, N.C., said that many vulvodynia patients have psychosexual issues but also described them as a result of the illness.

“Depression, anxiety, psychosexual dysfunction is rarely, if ever, a cause of vulvodynia. I don't discount the possibility that it may occasionally happen,” said Dr. Edwards, also of the University of North Carolina at Chapel Hill.

Dr. Edwards, a dermatologist who specializes in vulvar disorders, said she encourages patients to go for counseling, but most won't go. She said her message is “not 'You're crazy, and that makes you hurt,' but 'You hurt, and that will make you crazy.'”

Sexual abuse is a major underlying factor for vulvodynia patients, according to Esperanza McKay, M.D., a biofeedback clinician at the Pain Management Center in Houston. That should not cause anyone to underestimate the women's suffering, she advised.

“Their pain is really very real,” she said. “The first thing I do is listen to them. You will be amazed at how many have been sexually abused.”

Dr. McKay recommended waiting 3 or 4 months until a treatment begins to succeed before bringing up counseling. Many patients do not trust psychiatry and need to develop trust in the clinician before they will agree to go for counseling, she said.

Peter J. Lynch, M.D., a professor emeritus at the University of California, Davis, also advocated psychiatric help, warning that extreme cases can be the result of severe sexual abuse. “I happen to believe that psychosexual issues are an important cause of vulvodynia,” he said.

HOUSTON — A new guideline for the diagnosis and treatment of vulvodynia offers multiple treatment options, including experimental and complementary therapies, for the controversial disorder.

“We have oceans of lotions, potions, and notions out there for vulvodynia. There is not going to be one simple cure,” Hope K. Haefner, M.D., the lead author of a paper detailing the guideline, said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

What is clear, she said, is, “We have to do a lot more than say, 'Love burns.'”

Dr. Haefner, director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, recruited a panel of vulvar disease experts to draft the guideline at the request of the American Society for Colposcopy and Cervical Pathology (ASCCP). The guideline is published in the society's journal and can be accessed at www.jlgtd.com

Women's physicians are increasingly aware of vulvodynia but need to start treatment early, according to Dr. Haefner. “The longer a patient has the pain, the less likely we are going to be able to cure” her, she said.

The guideline uses terminology the International Society for the Study of Vulvovaginal Disease (ISSVD) recently adopted for vulvodynia, which has had multiple names, including vulvar vestibulitis syndrome and vulvar dysesthesia. The ISSVD defined vulvodynia as “vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder.”

Symptoms are not necessarily caused by touch or pressure to the vulva, such as with intercourse or bicycle riding, but these activities often exacerbate the symptoms.

The guideline also classified vulvodynia according to whether pain is generalized or localized. (Dr. Haefner cited vestibulodynia, clitorodynia, and hemivulvodynia as examples of localized pain.)

The ASCCP guideline recommends cotton swab testing along with the taking of a complete medical history for diagnosis. Health care providers should use the swab to test various locations of the vulva, including the labia majora, the labia minora, the interlabial sulci, and the vestibule at the clock positions of 2:00, 4:00, 6:00, 8:00, and 10:00. The degree of pain at each location should be recorded. Vaginal culture should be done to rule out conditions such as yeast infection.

Treatment recommendations start with gentle care for the vulva. This includes wearing cotton underwear and nonirritating menstrual pads, avoiding irritants, and using mild soap. Patients are urged to pat the vulva dry. Other suggestions include lubrication during intercourse, cold packs for irritation, and rinsing and drying the vulva after urination.

The guideline lists the following topical medications as useful for vulvar pain but with caveats and suggests that stopping all treatments may bring relief to some women who are using multiple topical medications:

▸ Lidocaine ointment 5% (various forms) is the most commonly prescribed topical treatment.

▸ Plain petroleum jelly can help symptoms.

▸ Estrogen has had variable results; however, Dr. Haefner questions how it works, given that many vulvodynia patients have low estrogen-receptor expression.

▸ Capsaicin is cited for neuropathic pain, but again, Dr. Haefner was skeptical that it works because this agent is an irritant.

▸ Nitroglycerine in one study improved vulvar pain and dyspareunia temporarily but caused headaches.

▸ Baclofen 2% (Lioresal) and amitriptyline 2% in a water-washable base can soothe point tenderness and vaginismus.

Topical corticosteroids, testosterone, and antifungal medications have not benefited vulvodynia patients, according to the guideline. Dr. Haefner also warned against use of benzocaine in these patients, which she said could cause rebound vasodilation and pain.

Oral medications for vulvodynia generally fall into two classes: antidepressants and anticonvulsants. If these are used, the guideline warns health care providers to check for drug interactions with other medications the patient is taking.

Dr. Haefner said tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline have had a 65%-70% response rate in multiple studies. When they are prescribed for pain management, smaller doses are recommended than for depression. Selective serotonin reuptake inhibitors such as venlafaxine are another option.

Dr. Haefner said she has also used duloxetine (Cymbalta), but a controlled study is needed to assess its efficacy in vulvodynia patients. The guideline also cites the use of anticonvulsants gabapentin (Neurontin) and carbamazepine.

Other guideline recommendations include biofeedback and physical therapy, intralesional injections in patients with localized pain, and surgery as a last resort in patients with vestibulodynia. Surgery is also an option in rare cases of pudendal nerve entrapment.

“The one time I do surgery without trying the other treatments discussed is when they have a lot of redundant tissue that is painful and tears with intercourse. Then I just resect that tissue,” Dr. Haefner said.

The guideline notes without judgment that many women use complementary and alternative therapies “before, during, and after seeking conventional medical diagnosis and treatment for their vulvar pain symptoms.” These include acupuncture, calcium citrate, low-oxalate diets, oatmeal water and saltwater baths, and, according to Dr. Haefner, hypnosis and botulinum toxin (Botox) injections.

“There are a lot of different things out there that need to be duplicated in different studies,” she said, describing low-oxalate diets, in particular, as controversial.

Finally, the guideline says vulvodynia is not a psychopathologic condition, but patients should receive emotional and psychological support during treatment.

For more information, contact the International Society for the Study of Vulvovaginal Disease by calling 704-814-9493 or go towww.issvd.org

Experts Dispute Psychosexual Factors

The new vulvodynia guideline rejects the assumption that vulvar pain without a clinically identifiable cause is all in a woman's head but notes that “sex therapy, couples counseling, psychotherapy, or a combination thereof” can be very helpful to patients.

“For years, there were people who thought it was a psychosomatic illness, and there are some people who still do believe that,” Dr. Haefner said. “I don't think it is. However, psychologically, many of our patients are depressed.”

The first description of vulvodynia in an 1880 medical textbook called the condition “hyperaesthesia of the vulva,” she said.

Although it has become more prevalent following recent media attention to women's accounts of the disorder, vulvodynia affects far more women and has been around far longer than has been recognized, she said.

Just what causes vulvodynia is still unclear. Dr. Haefner cited current thinking that the condition is neurologic or inflammatory in origin. (She leans toward neurologic but acknowledged it could be both.) Although she discounted sexual abuse as no more common in vulvodynia patients than in the general population, she said that it could be a factor in individual cases.

Elizabeth “Libby” Edwards, M.D., chief of dermatology of the Southeast Vulvar Clinic in Charlotte, N.C., said that many vulvodynia patients have psychosexual issues but also described them as a result of the illness.

“Depression, anxiety, psychosexual dysfunction is rarely, if ever, a cause of vulvodynia. I don't discount the possibility that it may occasionally happen,” said Dr. Edwards, also of the University of North Carolina at Chapel Hill.

Dr. Edwards, a dermatologist who specializes in vulvar disorders, said she encourages patients to go for counseling, but most won't go. She said her message is “not 'You're crazy, and that makes you hurt,' but 'You hurt, and that will make you crazy.'”

Sexual abuse is a major underlying factor for vulvodynia patients, according to Esperanza McKay, M.D., a biofeedback clinician at the Pain Management Center in Houston. That should not cause anyone to underestimate the women's suffering, she advised.

“Their pain is really very real,” she said. “The first thing I do is listen to them. You will be amazed at how many have been sexually abused.”

Dr. McKay recommended waiting 3 or 4 months until a treatment begins to succeed before bringing up counseling. Many patients do not trust psychiatry and need to develop trust in the clinician before they will agree to go for counseling, she said.

Peter J. Lynch, M.D., a professor emeritus at the University of California, Davis, also advocated psychiatric help, warning that extreme cases can be the result of severe sexual abuse. “I happen to believe that psychosexual issues are an important cause of vulvodynia,” he said.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised physicians not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised physicians not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised physicians not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. Patient wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar HPV lesions are highly variable, and the most common forms are:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step, he said, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatments can be quite effective. Electrosurgery, excision, laser therapy (all requiring anesthesia) can have a 100% response rate, while cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil (without anesthesia) will lead to complete clearance in two-thirds of patients.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said.

His recommendation: Use home therapy or go to destructive therapy and expect at least a 35% recurrence rate with either approach. A caveat: Dr. Lynch said vulvar warts should be treated in pregnant women, but warned that podophyllin and its derivatives should not be used.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. Patient wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar HPV lesions are highly variable, and the most common forms are:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step, he said, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatments can be quite effective. Electrosurgery, excision, laser therapy (all requiring anesthesia) can have a 100% response rate, while cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil (without anesthesia) will lead to complete clearance in two-thirds of patients.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said.

His recommendation: Use home therapy or go to destructive therapy and expect at least a 35% recurrence rate with either approach. A caveat: Dr. Lynch said vulvar warts should be treated in pregnant women, but warned that podophyllin and its derivatives should not be used.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. Patient wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar HPV lesions are highly variable, and the most common forms are:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step, he said, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatments can be quite effective. Electrosurgery, excision, laser therapy (all requiring anesthesia) can have a 100% response rate, while cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil (without anesthesia) will lead to complete clearance in two-thirds of patients.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said.

His recommendation: Use home therapy or go to destructive therapy and expect at least a 35% recurrence rate with either approach. A caveat: Dr. Lynch said vulvar warts should be treated in pregnant women, but warned that podophyllin and its derivatives should not be used.