Chronic vulvar pain, recurrent candidiasis and familial diabetic risk

Chronic vulvar pain, recurrent candidiasis and familial diabetic risk
Critical factors emerged from the VuNet on 1183 women – Part II

Alessandra Graziottin1,2 – Orcid, Dania Gambini2, Elena Boero2– Orcid, Filippo Murina3,4 – Orcid, ricercatori del gruppo Vu-net 

1 – Center of Gynecology and Medical Sexology, H. San Raffaele Resnati Milan

2 – Graziottin Foundation for the treatment of pain in women – Onlus

3 – Lower Genital Tract Pathology Service, V. Buzzi Hospital – University of Milan

4 – Italian Vulvodynia Onlus Association

Corresponding author: Alessandra Graziottin

direzione@studiograziottin.it


DOI: 10.53146/lriog1202127

Abstract

The VuNet (Vulvodynia Network) Project is an observational study set out to investigate the epidemiological characteristics and comorbidities of chronic vulvar pain. It involved 1183 women, enrolled between December 2016 and November 2018 in 21 Italian medical centers. Supported by the collected evidence that 32% patients with vulvar pain were affected by recurrent vulvo- vaginal candidiasis (RVVC), this article aims at analyzing the role of Candida infections in the genesis of vulvar pain and dyspareunia, and diabetes, or familiarity for diabetes, as a key predisposing factor. The recurrent/persistent inflammation associated with an aberrant immune-allergic reaction to Candida antigens may be a strong co-factor for developing vestibulodynia in this cluster of patients. The co-prevalence of 17.5% patients reporting food or respiratory allergies suggests a parallel predisposition to the development of allergic reactions. The anamnesis revealed a higher rate of diabetes in first- and second-degree relatives of the patients, both from the mother’s (8.4%) and father’s side (8.6%), versus the Italian national prevalence of 5.3% for the population un- der 65. Genetic predisposition for diabetes alters the carbohydrate metabolism predisposing to vulvovaginal candidiasis. Collectively, our data highlight the importance of investigating metabolic vulnerabilities to diabetes, both in the patient and her family, and encourage appropriate lifestyles, including: a net reduction in the consumptions of glucose or saccharose, body weight control, and daily aerobic exercise to reduce peripheral insulin resistance. The ultimate goals are reducing predisposing factors for candidiasis, vestibulodynia and coital pain in this cluster of patients, and tailoring treatment accordingly.

Keywords: vulvovaginal candidiasis; vulvar pain; vestibolodynia; dyspareunia; diabetes.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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Gonorrhea, a threatening infection in gynecology and obstetrics

Gonorrhea, a threatening infection in gynecology and obstetrics

Alessandra Graziottin1,2 – Orcid , Elena Boero1– Orcid  , Chiara Limongi

1 –  Graziottin Foundation for the treatment of pain in women – Onlus

2 – Center of Gynecology and Medical Sexology, H. San Raffaele Resnati Milan

Corresponding author: Alessandra Graziottin

direzione@studiograziottin.it


DOI: 10.53146/lriog1202126

Abstract

Gonorrhea is the second most common sexually transmitted bacterial infection worldwide after chlamydia. Women present a different and unsuspected gender vulnerability, with diagnostic and therapeutic delays that can and must be avoided. Gonorrhea is caused by the vertically and sexually transmitted bacterium Neisseria gonorrhoeae, whose prevalence is aggressively increasing worldwide. Diagnostic and therapeutic timeliness in women is hampered by lack of specificity and short duration of cervico-vaginal symptoms, modesty of urethral symptoms (urethritis), and limited knowledge of both oral and anal infections. Another element of insidiousness is the underestimation of the risks that gonorrhea entails, in terms of infertility and obstetric complications, chronic pelvic pain and injuries in distant organs, including conjunctivitis and gonococcal arthritis. The danger of the diagnostic delay is also expressed in the persistent infectivity of the patient, who continues infecting his/her sexual partners, and the fetus, in case of pregnancy. Growing antibiotic resistance is another serious alarm. The aim of the work is: to identify the key points for timely and effective diagnosis and treatment of gonorrhea in gynecology and obstetrics, with a focus on vaginal, endometrial, tubal, and pelvic; amniotic, placental, and fetal; oral and systemic vulnerability. Diagnostic difficulties and the current lack of a vaccine will be analyzed. The ultimate goal is to enhance the diagnostic and therapeutic timeliness of the gynecologist, in order to avoid both persistent underlying infectivity and multiple long-term complications.

Keywords: gonorrhea; sexually transmitted infection; gender vulnerability; infertility; antibiotic resistance.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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The vagina: therapeutic role of estrogens

The vagina: therapeutic role of estrogens

Anna Maria Paoletti– Orcid , Manuela Neri2

1 – Full Professor of Gynecology and Obstetrics, University of Cagliari

2- Medical Director at the Gynecological Oncology Division of the Oncology Hospital of Cagliari, Brotzu Hospital (AOB)

Corresponding author: Anna Maria Paoletti

annapaoletti@unica.it


DOI: 10.53146/lriog1202125

Abstract

Estrogen plays a key role in the physiology of the vagina. The multi-layering of the vaginal epithelium is regulated by estrogen, as well as the function of the cervical glands, connective trophism, vascularization and the local immune system itself. All conditions of hypoestrogenism, be they physiological such as menopause, the menopausal transition period, the puerperium and jatrogens as treatments for estrogen dependent diseases, but also the use of hormonal contraceptives containing only progestin or low doses of ethinylestradiol are risk factors for atrophy of vagina and urinary tract, which is also modulated by estrogen. In all conditions of hypoestrogenism, detectable by a correct medical history, the Gynecologist must ask specific questions about the specific symptoms both in the fertile age and after the menopause, focusing on the genitourinary syndrome. A careful examination must make a differential diagnosis with dermatological or autoimmune diseases, and evaluate the intensity of the problem with internationally validated scales. Once the diagnosis has been established and contraindications to the use of estrogen have been excluded, the first-line treatment is the use of vaginal estrogens, such as estriol, estradiol or promestriene and conjugated estrogens. The proposed treatment must be monitored at regular intervals to assess its effectiveness, safety and acceptability.

Keywords: genitourinary syndrom; ospemifene; dyspareunia; vulvar atrophy; vaginal atrophy; dysuria.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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The vagina: therapeutic role of ospemifene

La vagina: ruolo terapeutico dell’ospemifene

Novella Russo – Orcid

Demetra Medical Center: Center for Menopause

novella_russo@virgilio.it


DOI: 10.53146/lriog1202124

Abstract

The Genitourinary Syndrome of Menopause (GSM) is a progressive chronic condition that can be very bothersome for women. This disease, mainly due to the endocrinological changes occurring with menopause, is characterized by symptoms such as vaginal dryness, dyspareunia, itching, burning and dysuria. The marketing of a relatively new drug, Ospemifene, for the treatment of this clinical condition has given a new therapeutic option and prospective for a better quality of life in women affected by VulvoVaginal Atrophia (VVA). Ospemifene is a Selective Estrogen Receptor Modulator (SERM) and can also be prescibed to women with a history of breast cancer. The oral route of administration has shown to give higher adherence to treatment being preferable for many women to the vaginal route with a high satisfaction rate. In this article the main characteristics of the effects of Ospemifene on GSM have been elucidated and some of the most interesting studies have been illustrated. Women’s wording has been reported and particular attention given to their personal and familiar histories. Objective vulvar examination is described and aspects to be analysed in deep are reported. Therapeutic suggestions of a multimodal approach to the disease are made, although on this matter further scientific studies showing solid data are needed.

Keywords: genitourinary syndrom; ospemifene; dyspareunia; vulvar atrophy; vaginal atrophy; dysuria.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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The vagina: therapeutic role of prasterone

The vagina: therapeutic role of prasterone

Linda Vignozzi1,2 – Orcid, Irene Scavello1 – Orcid, Elisa Maseroli1 – Orcid, Vincenzo Di Stasi– Orcid, Sarah Cipriani1,2 – Orcid

1 – Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence

2 – SODc Andrology, Female Endocrinology and Gender Incongruence, Careggi University Hospital, Florence

Corresponding author: Linda Vignozzi

linda.vignozzi@unifi.it


DOI: 10.53146/lriog1202123

Abstract

Genitourinary menopause syndrome (GSM) is a chronic, progressive condition, which results from the effects of estrogenic and androgenic deficiency typical of menopausal age. It involves the genitourinary district and occurs with an extremely wide range of signs and symptoms. Dyspareunia, both superficial and deep, is among the main and most distressing symptoms of the GSM. Over the decades, different therapeutic approaches have been developed, aimed at improving the symptomatology and thus the quality of life of women, such as local estrogenic therapy, which until now has been considered the gold standard of GSM treatment. A new Prasterone formulation has recently been approved, which is biochemically and biologically identical to that of the endogenous human DHEA, an inactive steroid precursor that can be converted into estrogen and androgen into vaginal cells. The rationale of the use of prasterone is the theory of intracrinology, which is the proven ability of vaginal cells to convert an inactive compound into an active form. This molecule, absorbed locally, determines only a minimum increase in circulating hormonal values, which remains be- low the threshold of physiologic levels for menopausal women.

Keywords: prasterone; genitourinary syndrome; menopause; atrophy.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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The vagina: emerging evidence on the anti-inflammatory role of testosterone

The vagina: emerging evidence on the anti-inflammatory role of testosterone

Linda Vignozzi1,2– Orcid, Elisa Maseroli1 – Orcid, Ilaria Cellai2, Sandra Filippi3, Paolo Comeglio2, Sarah Cipriani2 – Orcid, Irene Scavello2 – Orcid, Giulia Rastrelli2 – Orcid, Margherita Frison2, Mario Maggi2 – Orcid

1 – SODc Andrology, Female Endocrinology and Gender Incongruence, Careggi University Hospital, Florence

2 – Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence

3 – Department of Neuroscience, Psychology, Pharmaceutical and Child Health Area, University of Florence

Corresponding author: Linda Vignozzi

linda.vignozzi@unifi.it


DOI: 10.53146/lriog1202122

Abstract

The female genitourinary tract is constantly exposed to infectious and inflammatory insults. Inflammation is an essential mechanism, usually able to restore tissue homeostasis; however, uncontrolled and self-maintaining inflammation can lead to dysfunctional processes, which may contribute to the onset of chronic conditions affecting the female genitourinary tract. These include the Genitourinary Syndrome of Menopause (GSM), characterized by vulvovaginal atrophy and symptoms of the lower urinary tract. The primary cause of GSM is a drop of estrogen levels at menopause; however, a decline in androgen level and chronic inflammation also play a pathogenic role. Androgen signaling generally suppress the activity of immune cells. In recent years, androgens have been described to play a key role in maintaining vaginal health, by positively regulating vascular and non-vascular smooth muscle and collagen growth and function, nerve density and function, and genital hemodynamics. Recent in vitro evidence also suggests an anti-inflammatory action of androgens within the vagina. In fact, it has been shown that hu- man vagina smooth muscle cells are able to be involved in the inflammatory response, behaving as resident nonprofessional antigen presenting cells and producing cytokines, chemokines and growth factors. Testosterone, ac- ting through its more active metabolite DHT (Dihydrotestosterone), seems to exert a relevant anti-inflammatory effect on vagina smooth muscle cells, blunting their ability to respond to inflammatory stimuli and to perpetuate inflammation. In particular, DHT counteracts the secretion of Interferon (IFNg), the most potent Th1 cytokine, which plays a key role in development of autoimmunity and chronic, self-perpetuating inflammatory diseases. These data suggest that androgens represent a potential therapeutic strategy for the GSM and other inflammatory conditions of the female genitourinary tract, to be further investigated in clinical studies.

Keywords: androgens; menopause; vagina; inflammation; infection.


Available in LRIOG Nr.2 – 2021

e-ISSN: 1824-0283


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