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Objective To develop a best practice document for the management of postmenopausal vulvovaginal atrophy (VVA). Method Literature review carried out using clinical terms, treatments or interventions and comorbidity related to VVA. Results There is a wide variety of interventions that may produce temporal benefits for VVA. However, there are significant limitations in scientific publications concerning VVA and related issues, including variable outcome evaluations, variability in population age range, and small, often underpowered sample sizes. Therapeutic management of VVA should follow a sequential order, considering women's age, symptoms, general health as well as treatment preference. Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application. In women with general menopausal symptoms who are candidates for systemic hormone therapy, the lowest effective dose should be used. Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA. Systemic androgens have a limited role. Although laser procedures are commonly used, at this moment the International Society for the Study of Vulvovaginal Disease does not endorse its use out of the setting of clinical trials. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first line therapy. However, limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors. As clinical practice and available preparations vary between countries this text should be adapted to local circumstances. Conclusions There is a wide range of therapeutic options to individualize VVA treatments.

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

Female genital cosmetic surgeries (FGCSs) and procedures are increasingly being advertised as common, simple, and complication-free, capable of not only improving aesthetic appearance but also increasing self-esteem and sexual pleasure.Guidelines for physicians and clear, scientifically correct information for patients must be made available, to minimize the number of ineffective or deleterious procedures.The International Society for the Study of Vulvovaginal Disease positions/recommendations regarding FGCS are as follows:1. There is a wide variation regarding genital normalcy; providers must be able to explain this to women.2. There are no data supporting FGCS including, G-spot augmentation, hymenoplasty, vulvar and perianal bleaching/whitening, vaginal tightening procedures, and other procedures aimed at increasing sexual function.3. Women should not be offered FGCS before the age of 18 years.4. Women undergoing FGCS should be evaluated by a provider with expertise in vulvovaginal diseases, including attention to their psychological, social, and sexual context. Evaluation by an experienced mental health provider should be considered when the motivation for seeking surgery and/or expectations are not clear or realistic.5. Female genital cosmetic surgery is not exempt from complications.6. Informed consent must always be obtained.7. Surgeons performing FGCS should refrain from solicitous advertising or promoting procedures without scientific basis, including on Web sites.8. Surgeons should not perform surgery that they do not agree with and explain their rationale/position when pressured by patients.9. The genital surgeon must be adequately trained in performing FGCS including knowledge of the anatomy, physiology and pathophysiology of the vulva, vagina and adjacent organs.

The appearance of the female external genitalia is key for understanding and diagnosing many diseases that women of all ages encounter. Alas, the normal appearance of the vulva and its diversity is not always presented both to patients and to caregivers. This chapter reviews vulvar and vaginal embryology, its anatomy, the changes in the female external genitalia throughout the woman’s life cycle, and literature discussing vulvar measurements.

The appearance of the female external genitalia is key for understanding and diagnosing many diseases that women of all ages encounter. Alas, the normal appearance of the vulva is an elusive concept, scarcely represented in textbooks, and the growing number of vulvar cosmetic surgery calls for a review of the normal appearance of the vulva and its diversity. In this paper I will review vulvar embryology, anatomy, the current literature discussing vulvar appearance, and describe meticulous vulvar examination, including the diagnostic tools.

BACKGROUND Osteomyelitis of the pubic bone is a rare entity. Risk factors for infection of the symphysis pubis and osteomyelitis of the pubic bone include direct trauma, previous urogynecologic procedures, extreme physical exercise, and immunocompromised state. The treatment modalities range from conservative antibiotic treatment to extensive surgery. CASE A 49-year-old woman with multiple sclerosis and borderline diabetes mellitus presented with bloody vulvovaginal discharge. The source was found out to be an ulcer located above the urethra with exposure of the underlying symphysis pubis. Intraoperative debridement of the ulcer followed by bone biopsies demonstrated osteomyelitis of the pubic bone. Prolonged intravenous antibiotics and 4 operative debridements were needed before the osteomyelitis was adequately addressed and the defect could be closed with a bulbocavernosus flap. CONCLUSIONS This is the first report of a severe case of osteomyelitis of the pubic bone arising from a vulvar ulcer.

Objective Vulvar varicosities are not uncommon in pregnancy, but there are only a few published reports of symptomatic vulvar varicosities in nonpregnant women. Case We report 2 cases of women presenting with symptomatic vulvar masses that were more prominent after exercise or with elevated intra-abdominal pressure. Symptoms included an intermittent vulvar bulge or mass and moderate pain when the masses were present. Imaging studies did not reveal the nature of these masses. On surgical exploration, they were found to be large vulvar varicosities. Conclusions Vulvar masses can be caused by hernias, tumors, cysts, or other unusual entities. Differentiating among these etiologies can be a diagnostic challenge. Although most often a positional vulvar mass is a sign of hernia, it is important to be aware that masses that come and go can be caused by other entities, including large varicose veins.

To evaluate the efficacy of methotrexate treatment for extrauterine pregnancy and define criteria for prediction of success.Of 829 patients with an ectopic pregnancy admitted to E. Wolfson Medical Center, Holon, Israel, from January 1997 through December 2009, 238 had asymptomatic tubal pregnancies and increasing serum β-human chorionic gonadotropin (βhCG) levels. These patients were treated with a single intramuscular injection of 50mg of methotrexate (MTX) per square meter of body surface. Success was defined as undetectable βhCG levels without the need for a surgical intervention.The groups of patients successfully treated (n=167 [70%]) and unsuccessfully treated (n=71 [30%]) were compared. They were similar regarding age and gravidity. The initial serum βhCG level was significantly higher in the latter group than in the former (3798 mIU/mL vs. 1601 mIU/mL, P0.01). The success rate was 88% when initial βhCG levels were less than 1000 mIU/mL, 71% when they were between 1000 and 2000 mIU/mL, and only 59% when they were between 2000 and 3000 mIU/mL.Methotrexate treatment is a safe and effective alternative to surgery. However, patients with initial βhCG levels higher than 2000 mIU/mL should only be offered the surgical approach.

Chronic vulvar pruritus and vulvodynia are common vulvar diseases. The aim of this study was to compare gynecologic and sexual and physical abuse histories from patients with these diagnoses and from healthy controls.Questionnaires were self-completed by patients diagnosed with vulvar itch-scratch (n = 93), patients diagnosed with vulvodynia (n = 232), and patients presenting for annual gynecologic examinations (n = 104) at the University of Michigan Hospitals, Ann Arbor, MI.Patients who came for annual examinations were less likely to report past gynecologic infections (p.05) and indicated higher interest in and more frequent sexual activity than the other 2 groups (p = .003). Vulvodynia patients had the highest scores on the McGill Pain Questionnaire (p.001). Subjects with either vulvar disorder were more likely to self-report a history of gynecologic infections than annual examination controls. Rates of sexual (p = .78) and physical abuse (p = .12) were similar for all 3 groups.Patients with vulvar pruritus and vulvodynia report similar rates of sexual and physical abuse.

To describe the normal appearance and the growth of the fetal vermis, pons and midline brainstem by ultrasound from 18 weeks of gestation to term in order to produce developmental nomograms.Serial ultrasound examinations of the fetal brain were performed in 21 fetuses between 18 and 39 weeks of gestation every two weeks. A total of 173 examinations were done, 8.2 ± 5.2 examinations per fetus. A mid-sagittal plain of the brain was obtained either by transvaginal or transabdominal sonography. Antero-posterior, cranio-caudal diameters, and surface area of the pons and the vermis were measured. The surface area of the brain stem was also measured. Nomograms were produced according to Royston and Wright.The pons, vermis and brain stem grow in a linear fashion throughout pregnancy. The growth pattern correlates well with gestational age, biparietal diameter, head circumference and the cerebellar transverse diameter.We have provided nomograms for assessment of the fetal brainstem. The present information supplies tools for the accurate identification of fetal mid-hindbrain anomalies providing a solid basis for a multidisciplinary approach, management and counseling of these conditions.

Fetal echocardiography accurately detects congenital cardiac anomalies, but it is costly, time-consuming, and requires highly-skilled operators. Our aim was to define those patients for whom fetal echocardiography is justified.The files of 1696 consecutive patients who underwent second- to third-trimester fetal echocardiography at our tertiary center between 1997 and 1999 were reviewed for reason for referral, echocardiography diagnosis, and pregnancy outcome.The patients were categorized by reason for referral into high-and low-risk groups. The high-risk group included 662 patients (39%) with fetal risk factors, 178 (10.5%) with maternal risk factors and 279 (16.5%) with poor obstetric history. The remaining 577 women (34%) were considered low-risk population. These included 282 self-referred women (due to maternal anxiety) who served as control group, 78 women who were referred because of a suspected cardiac malformation on routine second-trimester ultrasound, and 213 women who were referred because of failure to view the heart on second-trimester ultrasound. In 46 women, cardiac anomalies (2.7%) were detected prenatally and confirmed postnatally; most of them (41/46, 89%) were in the low-risk population. Abnormal cardiac findings on second-trimester ultrasound and a diagnosis of a single umbilical artery made the most significant contribution to the detection of cardiac abnormalities (p0.001 and p = 0.02, respectively).Most fetal cardiac malformations occur in the low-risk population. Abnormal view of the fetal heart on routine second-trimester screening is highly predictive of congenital cardiac anomalies.

Purpose: The aim of this study was to investigate the effect of thromboprophylactic therapy on fetal and maternal Doppler flow parameters in pregnant women with severe complications in previous pregnancies and evidence of acquired or congenital thrombophilia in the current pregnancy. Methods: Sixty-five patients with a history of recurrent abortions, intrauterine fetal death, intrauterine growth restriction (IUGR), and severe early-onset preeclampsia were tested for the presence of acquired or congenital thrombophilia. Those with positive findings were prescribed low-dose aspirin plus low-molecular-weight heparin (LMWH) (enoxaparin); the remainder received low-dose aspirin only. A Doppler flow study was performed before and after treatment and in the third trimester of pregnancy. Results: Of the 65 pregnancies, four ended in spontaneous abortion and were excluded from the analysis. Of the 61 women with completed pregnancies, 37 (61%) had evidence of acquired or congenital thrombophilia: 22 (36%) protein S deficiency; 1 (2%) protein C deficiency; 2 (3%) activated protein C resistance (APC-R); 2 (3%) IgG for antiphospholipid antibodies; 1 (2%) circulating anticoagulant; and 9 (15%) a combined defect. This group showed a significant decrease in mean uterine artery pulsatility index (PI) before and after treatment (1.32±0.36 vs. 1.04±0.23, P =.006), whereas the remaining 24 patients treated with low-dose aspirin only had nonsignificant changes. Pearson's correlation test yielded no correlations of the pregnancy outcome parameters with Doppler flow values in the umbilical or uterine arteries. Conclusions: Thromboprophylactic therapy transiently improves maternal circulation parameters in patients with thrombophilia at risk of fetal loss and other severe complications of pregnancy, but not in correlation with their pregnancy outcome. Therefore, Doppler examination of maternofetal circulation in the second trimester is not predictive of pregnancy outcome.

Objective: Low-molecular-weight heparin (LMWH) is the anticoagulant of choice during pregnancy because it is associated with a low incidence of osteoporosis and thrombocytopenia. Antithrombotic therapy has recently been used to prevent pregnancy loss in high-risk patients with evidence of acquired or congenital thrombophilia. The aim of the present study was to gain further information on the teratogenic potential of LMWH in this patient group. Methods: The study population included 46 patients with a history of recurrent abortions, intrauterine fetal death or intrauterine growth restriction (IUGR) and severe early-onset preeclampsia. Patients with a history of thromboembolism or positive findings for thrombophilia were prescribed LMWH (enoxaparin sodium, 40 mg daily) in combination with low-dose aspirin (100 mg daily) in the first trimester (group 1, n=14) or the second trimester (group 2, n=17); the remaining 15 patients received low-dose aspirin alone (group 3). Results: No significant differences were noted between the groups in the incidence of congenital malformations or abortions, IUGR or preterm deliveries. One infant in group 1 had familial bilateral postaxial polydactyly of the hands and one in group 3 had patent ductus arteriosus. Conclusion: Despite the small size of the study groups, our results support the assumption that the use of LMWH is safe, at least as a teratogenic agent, in patients with thrombophilia throughout pregnancy.