LRIOG 2021-1

Androgens and genitourinary syndrome of the menopause. Why, when and for whom they could be indicated

Editor ArticlesLRIOG 2021-1 , , , , .
Androgens and genitourinary syndrome of the menopause. Why, when and for whom they could be indicated

Alessandra Graziottin – Orcid

Director of the  Gynecology and Medical Sexology Center, H. San Raffaele Resnati, Milan

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

direzione@studiograziottin.it

DOI: 10.53146/lriog120212

Abstract

Why androgens – testosterone and dehydroepiandrosterone (DHEA) – can play a role in the treatment of the Genitourinary Syndrome of the Menopause? What evidence supports this? Androgens are essential sex hormones for women’s health. Biological evidence (“bio-evidence”) indicates the following: androgens reach high plasma levels in childbearing age; have cell receptors in major organs; the hormone-receptor interaction mediates androgen-mediated, somatic (brain, muscle, bone), sexual and reproductive functions; their deficiency causes symptoms of androgenic insufficiency. They have a trophic, sexual, anti-inflammatory, and reconstructive functions. DHEA launches puberty (adrenarche). Androgens reach their plasma peak at twenty years of age, then they undergo an age-dependent gradual fall. At the age of fifty, women have lost about 50% of testosterone and 60-70% of DHEA. Bilateral ovariectomy reduces testosterone by 80%. Their age-
dependent reduction, worsened by estrogen deficiency, contributes to systemic and genital aging and to the “low grade inflammation” typical of post-menopause. Genitourinary Syndrome of the Menopause includes vulvo-vaginal symptoms.

Keywords: androgens; prasterone; testosterone; genitourinary syndrome of the menopause (GSM).

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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Staphylococcus aureus vulvitis

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Staphylococcus aureus vulvitis: an insidious infection that stresses the importance of appropriate intimate hygiene

Alessandra Grazziottin1,2 – Orcid, Elena Boero1 – Orcid

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

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

Corresponding author: Alessandra Graziottin

direzione@studiograziottin.it

DOI: 10.53146/lriog1202113

Abstract

Why do folliculitis and other bacterial vulvar infections represent disorders of interest in the gynecological practice? Which predisposing, precipitating, and maintaining factors should be considered by the gynecologist when recurrent bacterial infections of vulvar skin become a clinical challenge? When is it appropriate to think of Staphylococcus aureus as a principle etiological agent? Why do S. aureus vulvar infections represent an emerging threat for women’s health? New hygienic and cosmetic practices, including over-zealous cleansing and micro- and macro-traumatic hair removal techniques, lead to a significant increase of vulvar infections in the clinical practice. Factors predisposing to bacterial vulvar infections, such as personal and familial diabetes and obesity, indicate to the gynecologist an alteration of the vulvar ecosystem, which can predispose to more severe pathologies. S. aureus, the main infectious agent, causes increasing medical concerns because of its pathogenic and invasive capacity. Moreover, the rapid ability of S. aureus of developing antibiotic resistances is even more challenging in surgical specialties, especially in obstetrics and gynecology, for the reduced availability of effective antibiotics for treatment. The gynecologist has an important educational role on the appropriate hygiene principles, to reduce bacterial vulvar infections, more threatening for their increasing invasive potential, especially in more vulnerable subjects.

Keywords: intimate hygiene; cutaneous infections; staphylococcus aureus; vulva.

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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Syphilis: why the disease is more insidious in women

Editor , ArticlesLRIOG 2021-1 , , , , , .
Syphilis: why the disease is more insidious in women

Alessandra Grazziottin1,2 – Orcid, Elena Boero1 – Orcid

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

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

Corresponding author: Alessandra Graziottin

direzione@studiograziottin.it

DOI: 10.53146/lriog1202112

Abstract

Why should syphilis be reconsidered in gynecological clinical practice? Why are women more vulnerable to late diagnosis? What are the key points for timely and effective diagnosis and treatment? What are the avoidable consequences of diagnostic and therapeutic delays? Syphilis is caused by the sexually and vertically transmitted bacterium Treponema pallidum. Syphilis, wrongly considered outdated, is making an aggressive comeback worldwide. From a medical point of view, diagnostic timeliness is hampered by: a lack of familiarity with this re-emerging disease and a consequent lack of consideration in the anamnestic picture and differential diagnosis; complex course, which alternates insidious and variable symptomatic phases, with periods of clinical latency, while the disease continues its pro-inflammatory and destructive action at the subclinical level. The late or missed diagnosis of syphilis leads to a prolonged infection, with permanent and at times fatal outcomes. The danger of a delay in diagnosis also results in persistent infectivity of the patients, who continue to infect their sexual partners, and the fetus, if pregnant. The aim of the work is: to identify the key points for timely and effective diagnosis and therapy of syphilis in gynecology, with a focus on vulvar and vaginal vulnerability; to analyze the reasons for its insidious hidden diffusibility; to discuss the diagnostic difficulties, the limited availability of the most effective drug, penicillin, the current lack of a vaccine and finally why it is difficult to follow the course of the disease and its therapy through laboratory diagnostics. The final goal is to enhance the diagnostic effectiveness of the gynecologist.

Keywords: syphilis; primary chancre; secondary syphilis; treponema pallidum; penicillin; vulva.

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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Vulvar pain and diagnosis of comorbidities

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Vulvar pain and diagnosis of comorbidities
Key factors from the Vu-Net study on 1183 cases – part 1

Alessandra Grazziottin1 – Orcid, Dania Gambini 2 – Orcid, Filippo Murina3,4 – Orcid e i ricercatori del gruppo Vu-Net

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

2 – Alessandra 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/lriog120215

Abstract

The Vu-Net (Vulvodynia Network) project is aimed at investigating chronic vul- var pain and its medical and sexual comorbidities, given its remarkable impact on the quality of life of both women and couples. The reported incidence of chronic vulvar pain (lasting 3-6 months) in women is 16%. This cross-sectional study involved 1183 patients with chronic vulvar pain attending 21 Italian medical centers from December 2016 to November 2018. 70.7% of enrolled women were between 20 and 49 years of age. Main diagnoses were spontaneous or provoked vestibulodynia (70.8%) and generalized vulvodynia (27.3%). The main reason for consultation was introital pain on penetration (64.2%), together with associated sexual dysfunctions, such as vaginal dryness (29.8%), hypoactive sexual desire disorder (22.1%) and sexual arousal disorder (21.3%). 48.3% had prolonged pain, lasting 1 to 5 years, with a mean diagnostic delay of 4 years and 7 months. The main comorbidities that emerged from the study include high association with intestinal disorders (94.7%), in particular IBS (27.3%), constipation (23.5%), and food allergies (10.1%); bladder infections (37.4%) including recurrent cystitis (19.5%) and post-coital cystitis (17.9%); recurrent vulvovaginal candidiasis (32%); headache (25.7%); mental disorders (22.6%); allergies (17.5%); endometriosis (11.7%). 77.4% of the Vu-Net patients had previously been treated without improving their condition. The analysis of the comorbidities allows the gynecologist to recognize the clusters of patients that will obtain the best results when treated with a multimodal intervention.

Keywords: chronic vulvar pain; dyspareunia; vulvovaginal candidiasis; comorbidities.

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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Vulvar herpes: clinics and therapy

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Vulvar herpes: clinics and therapy

Stefano Astorino – Orcid

Operational unit of dermatology and stds – “Celio” Military Polyclinic, Rome

stefano.astorino.sa@gmail.com

DOI: 10.53146/lriog1202111

Abstract

Most young people with erosive-ulcerative-genital lesions (“Genital Ulcer Disease”) have genital herpes (prevalence 5-40%), sometimes associated with syphilis or other sexually transmitted diseases, with a significant risk of co-infection with HIV.
Also transmissible in asymptomatic (virus shedding) or “undiagnosed” due to mild, atypical symptoms (fissures, erythema, neuralgia), or hidden localizations, the primary infection of vulvar herpes (HSV2-1) has classic acute manifestations: pain, burning (sometimes sciatica, cruralgia, antalgic urinary retention), cluster vesicle- pustules on erythematous-edematous areas that evolve into confluent-polycyclic erosions, often ulcerative-aphthous-like; satellite lymphadenitis, fever sometimes high. In 1-3 weeks they heal (completely the erosions; ulcers with scars); after weeks or months of latency the secondary herpes relapses on average 5-6 times a year, with variable duration (on average 1 week). Relapsing symptoms and signs, similar to primary-Herpes, are more localized and attenuated, except in immunosuppressed, who manifest chronic, severe-ulcerative, disabling, hypertrophic-pseudo-tumor, generalized-varicelliform forms. Possible cause of fetal malformations, neonatal morbidity and lethality, herpes in pregnancy is effectively treated with systemic acyclovir. Sometimes it justifies caesarean-section. According to European-guidelines (2017), the diagnosis is clinical (when possible supported by PCR); topical antiviral-therapy offers few advantages (except foscarnet 1% in case of resistance and imiquimod 5% effective in HIV-associated pseudotumoral-forms) compared to local soothing-antiseptic and anti-inflammatory (including cortisone) therapy. Acyclovir (ACV), since its discovery (Elion_G.B.1978) the best systemic antiherpetic, is effective both with “episodic-therapy” (average adult dose: ACV tbl 200-800mg 3t./die for 7-10 days in primary-Herpes, for 2-5 days at each relapse) both with “continuous-suppressive-therapy” (if>6 relapses a year a.a.d.:ACV400mg 2t./die or similar: Famciclovir FCV 250mg 2t./die, Valaciclovir VLC 500mg 1t./die; replaceable in case of resistance with Foscarnet 40mg / kgI.V./8-12h.).

Keywords: vulvar herpes; HSV2-1; genital herpes; systemic antiviral therapy; topical therapy; guidelines.

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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Extrammamary Paget’s disease of the vulva (EMPDV)

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Extrammamary Paget’s disease of the vulva (EMPDV), this unknown

Francesco Sopracordevole1 – Orcid, Nicolò Clemente1 – Orcid, Anna del Fabro1 – Orcid

1 – CRO (Centro di Riferimento Oncologico – Oncological Reference Centre)  Cancer Institute Aviano

Corresponding author: Francesco Sopracordevole

fsopracordevole@cro.it

DOI: 10.53146/lriog120214

Abstract

Extramammary Paget’s disease of the vulva (EMPDv) is a rare neoplasia, with only intraepithelial spread in most of the cases, slowly evolving, with aspecific symptoms and high recurrence rate.
Extensive surgery is often necessary with repeated excision in case of recurrent disease. This can lead to significant genital disfigurement and impairment of the quality of life. Less invasive treatments (radiotherapy, immunotherapy, photodynamic therapy, laser ablation) have variable response and high recurrence rate. In case of invasive disease, poorly responsive to radio/chemotherapy, if a HER2 overexpression is detected, excisional surgery followed by specific target therapy is showing promising results. The key factor for the optimal management of EMPDv is the prompt diagnosis and treatment of lesions, in a multidisciplinary approach with proper therapies and a long-term follow-up, preserving the patient’s genital function and self-image.

Keywords: vulvar extramammary paget’s disease; surgery; diagnosis.

Available in LRIOG Nr.1 – 2021

e-ISSN: 1824-0283

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