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BackgroundApproximately 26% of adult women in the United States suffer from female sexual arousal disorder (FSAD), yet little has been done to compare the experience of FSAD in pre- and postmenopausal women, which is critical to enhance the current understanding of FSAD and inform the development and assessment of treatment options for these patient populations.AimTo explore the experience of condition-associated symptoms and the relative importance of FSAD symptoms, including their severity, bother, and impact, on participants’ health-related quality of life (HRQoL) in pre- and postmenopausal women with FSAD.MethodsIn-depth, qualitative, semistructured concept elicitation interviews were conducted with premenopausal (n = 23) and postmenopausal (n = 13) women who were clinically diagnosed with FSAD by a trained sexual medicine clinician. All interviews were audio recorded and transcribed verbatim by a professional transcription company. Thematic analysis was performed with the assistance of NVivo qualitative analysis software.OutcomesOutcomes included qualitative interview data about FSAD symptoms and HRQoL, as well as a comparison between pre- and postmenopausal populations.ResultsThe most frequently reported symptom in both cohorts was “inability or difficulty with orgasm” (premenopausal, n = 21; postmenopausal, n = 13). The symptom that premenopausal women most desired to have treated was lubrication, and for postmenopausal women, it was a lack of lubrication or wetness and loss of feeling/sensation. In total, 21 of 23 premenopausal women and all 13 postmenopausal women reported a lack of feeling or sensation in the genitals. The most frequently reported HRQoL impact in both groups was decreased confidence.Clinical ImplicationsResults from this study suggest that the manifestation and experience of FSAD are similar in pre- and postmenopausal women and that the unmet need for an FSAD treatment in the postmenopausal population is just as great as that of the premenopausal population.Strengths and LimitationsThis study involved in-depth qualitative interviews with a relatively small group of women (N = 36) recruited from only 5 study sites across the United States.ConclusionThe analysis of qualitative data from the concept elicitation interviews revealed a substantial physical and emotional burden of FSAD, underscoring the need for Food and Drug Administration–approved treatment options for pre- and postmenopausal women with FSAD.

Topical corticosteroids are often utilized as the first-line treatment for vulvar lichen sclerosus (VLS). However, there is wide variability in dosing regimens, as well as a lack of consensus on maintenance dosing. Available guidelines on dosing frequency and regimen continuation for VLS are based on clinical expert opinion and do not necessarily reflect the pharmacokinetics of topical corticosteroids. Over the past few decades, there have been many advances in the techniques used to measure the local and systemic absorption of topical corticosteroids. These techniques have led to a greater understanding of the pharmacokinetics and bioavailabilities of these medications. However, it is not clear how this new information has been applied in evaluating dosing regimens and commonly cited risks when considering short- and long-term use in different vulvar dermatoses. This purpose of this review is to evaluate the available evidence on pharmacokinetics, absorption rates, and concentration levels of topical corticosteroids in lesional and nonlesional skin. Additionally, the evidence regarding commonly cited risks of topical corticosteroid use, including dermal thinning, adrenal suppression, systemic immunosuppression, and tachyphylaxis are reviewed. Differences in the effects of topical corticosteroids on the varied tissues of the vulva are specifically explored. Finally, these considerations are applied to evaluate the current treatment guidelines for VLS to provide direction in determining an evidenced-based dosing regimen and to inform future research in this area. Mautz TT, Krapf JM, Goldstein AT. Topical Corticosteroids in the Treatment of Vulvar Lichen Sclerosus: A Review of Pharmacokinetics and Recommended Dosing Frequencies. Sex Med Rev 2021;XX:XXX-XXX.

Background Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood. Aim To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management. Methods A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment. Outcomes The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed. Results The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients’ symptoms and the associated bother and distress. Clinical Implications The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment. Strengths and Limitations Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion. Conclusion We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women’s Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665–697.

Introduction Cervical cancer is the leading cause of cancer deaths in women in the developing world. New technologies have been developed to allow for more rapid, cost-effective, and sensitive cervical cancer screening and treatment. Aim The aim of this study was to describe methods for detection and treatment of human papillomavirus (HPV), cervical dysplasia (CD), and cervical cancer. New technologies and updated screening strategies will be emphasized. Methods A literature search was conducted using PubMed to identify publications relevant to the subject. Main Outcome Measure Sensitivity and cost-effectiveness of new cervical cancer screening methods were the main outcome measures. Results HPV and cervical cancer have a significant global impact. Research and innovations related to detection and treatment are key in reducing their burden worldwide. Conclusion Screening a woman for HPV and CD can dramatically decrease her risk of dying from cervical cancer. New, rapid, low-cost, HPV testing can allow for high-volume screening for the approximately 1.5 billion women who have never been screened. HPV screening can then be combined with high resolution digital colposcopy to detect CD. In the near future, these colposcopic images will be interpreted by artificial intelligence software. Detected lesions can then be treated easily and effectively with thermocoagulation. This see-and-treat model is a sensitive, efficient, and low-cost vision for the future.

Introduction Vulvodynia is defined as vulvar pain of at least 3 months duration without a clear identifiable cause. There are currently no validated questionnaires that assess the experience of women with localized vulvodynia of the vestibule (vestibulodynia, previously known as vulvar vestibulitis) that meet the requirements of the Food and Drug Administration's Patient Reported Outcome (PRO) Guidance. Aim To develop a new content-valid PRO assessment in accordance with the Food and Drug Administration's PRO guidance to assess the symptoms and impacts of localized vulvodynia. Material and Methods Participants were recruited for concept elicitation interviews (ie, interviews with open-ended questions with the goal of eliciting volunteered data about the symptoms and impacts of vulvodynia). Participants were identified as having localized vulvodynia by clinicians who were experts in treating vulvar disorders. Eligibility was confirmed by the recruiting clinician, and informed consent was obtained; participants were then scheduled for in-person interviews. 25 participants were interviewed from United States (US). After concept elicitation interviews, the draft Vulvodynia Experience Questionnaire (VEQ) was developed based on the results. Cognitive interviews were conducted with 20 participants from US sites to assess the content validity of the VEQ (eg, interpretation and clarity of the items, relevance of concepts). The VEQ was further revised after cognitive interviews. All interviews were conducted face-to-face, audio-recorded, transcribed verbatim, anonymized, and analyzed using a qualitative data analysis software program. Results 17 unique symptoms and 32 unique impacts were reported during concept elicitation interviews. Pain (n = 25, 100%) and burning (n = 24, 96%) were the most frequently reported symptoms of localized vulvodynia, and negative impact on emotional well-being (n = 25, 100%) was the most frequently reported impact. After analysis, item generation, and cognitive interviews, the resulting VEQ v2.0 contains 3 parts (part 1, pain; part 2, associated symptoms; part 3, impacts) with a total of 25 items that measure the most frequently reported symptoms and impacts of localized vulvodynia. Strength and Limitations The VEQ is a multidimensional assessment of the core symptoms and impacts of localized vulvodynia that, after additional psychometric testing including the ability to detect change, may be used in clinical trials to characterize the benefits of novel treatments. The VEQ requires additional testing to establish its cultural relevance and linguistic validity in other countries. Conclusion The VEQ is a novel method of collecting information on localized vulvodynia symptoms and impacts that may be suitable for use in clinical trials after psychometric testing.

Background Although spironolactone is an effective treatment for androgen-mediated cutaneous disorders, the potential sexual side-effects are poorly documented in current literature. Aim The purpose of this study was to provide clinical evidence that spironolactone may be a cause of hormonally associated vestibulodynia and female sexual arousal disorder. Methods A database search of a vulvar disorders clinic revealed 7 cases in which spironolactone may have caused or contributed to dyspareunia and decreased arousal. In all cases, the patients stopped taking spironolactone and used a compounded estradiol 0.01%/testosterone 0.1% gel to the vestibule twice daily. 2 cases are discussed to further illustrate these previously unreported side effects. Outcomes Improvement in sexual function was determined after treatment. Results Examination of women taking spironolactone who presented with the complaints of introital dyspareunia revealed vulvar vestibular atrophy and tenderness, especially at the glandular ostia. After stopping spironolactone and applying a topical estrogen/testosterone gel to the vestibule, all women had significant improvement in their vulvar atrophy, resolution of their dyspareunia, and improved sexual arousal. Clinical Implications Use of spironolactone may be a cause of hormonally associated vestibulodynia and female sexual arousal disorder. Strengths and Limitations The influence of spironolactone on vulvar health and sexual function is poorly documented in the medical literature. The strength of this paper is that it examines the potential deleterious side effects of this medication on female sexual function. However, the most significant limitation of this case series is that it was not a prospective, controlled study. Conclusions Although treatment of androgen-mediated cutaneous disorders is warranted, medical providers should be aware of the potential sexual side effects of this anti-androgenic medication.

Though a large number of women suffer from vulvar pain and dyspareunia, many clinicians feel that they lack the knowledge to adequately evaluate, diagnose, and treat women with vulvovaginal pain. This review examines the new International Society for the Study of Vulvovaginal Disease (ISSVD)/International Society for the Study of Women’s Sexual Health (ISSWSH)/International Pelvic Pain Society (IPPS) terminology of vulvar pain and vulvodynia, reviews a diagnostic algorithm that can help to differentiate between different types of vulvar pain, and discusses non-medical, medical, and surgical treatment options for provoked vestibulodynia (PVD; vulvodynia confined to the vestibule). The combination of this new terminology, diagnostic algorithm, and potential treatments will allow for more appropriately targeted treatments for women with PVD.

Physicians often feel challenged in the diagnosis and management of vulvar diseases and their effects on psychosexual health. Vulvar dermatoses must be considered in the differential diagnosis of women experiencing female sexual dysfunction or vulvovaginal pain. This review will focus on the diagnosis and treatment of common vulvar dermatoses, including vulvar contact dermatitis, lichen simplex chronicus, vulvar psoriasis, lichen sclerosus, lichen planus, and vulvar intraepithelial neoplasia. The impact of these disorders on sexual well-being will be emphasized. A detailed history and physical examination, backed by confident knowledge of vulvar dermatoses, will aid in diagnosis and management of these diseases. Current gold-standard treatments will be discussed as well as innovative therapeutic approaches currently being developed. With increased clinician awareness and further research, vulvar dermatoses and resulting sexual dysfunction can be appropriately managed.

Introduction Ospemifene (Osphena, Shionogi Inc, Florham, NJ, USA) is an estrogen agonist and antagonist approved by the U.S. Federal Drug Administration for the treatment of “moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause.” Although published, peer-reviewed, placebo-controlled studies have shown objective improvement in dyspareunia and in vaginal atrophy, there are no published data that have assessed changes in vulvar atrophy after the use of ospemifene. Aim To present two cases of women with severe vulvar atrophy that showed no improvement with the use of ospemifene. Methods A review of two recent cases of a clinic specializing in the treatment of vulvovaginal disorders was performed. Case 1 was a 53-year-old menopausal woman who presented with non-provoked vulvar and vaginal discomfort and introital dyspareunia. She had used ospemifene 60 mg/d for 1.5 years without improvement in her symptoms before presentation. Case 2 was a 57-year-old menopausal woman who also presented with non-provoked vulvar rawness, burning, irritation, vaginal dryness, and introital dyspareunia. She had started ospemifene 60 mg/d 1 year before presentation and reported mild improvement in her vaginal dryness but no improvement in her vulvar irritation or introital dyspareunia. Main Outcome Measures Change in vulvar atrophy and introital dyspareunia. Conclusion These cases highlight the need to perform additional clinical trials that specifically assess the efficacy of ospemifene for changes in vulvar atrophy.

Introduction In 2014, the Executive Council of the International Society for the Study of Vulvovaginal Disease (ISSVD), the Boards of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) acknowledged the need to revise the current terminology of vulvar pain, based on the significant increase in high quality etiologic studies published in the last decade. Methods The new terminology was achieved in four steps. The first involved a terminology consensus conference with representatives of the three societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended based on feedback from members of the societies. Finally, each society's board accepted the new terminology. Results and Conclusion In 2015, the ISSVD, ISSWSH, and IPPS adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

Introduction Vulvodynia constitutes a highly prevalent form of chronic genital pain in women, and current information regarding its definition, prevalence, impact, and pathophysiologic factors involved is needed. Aim To update the scientific evidence published in 2010 from the Third International Consultation of Sexual Medicine pertaining to the definition, prevalence, impact, and pathophysiologic factors of women's sexual pain. Methods An expert committee, as part of the Fourth International Consultation of Sexual Medicine, comprised of researchers and clinicians from biological and social science disciplines, reviewed the scientific evidence on the definition, prevalence, impact, and pathophysiologic factors related to chronic genital pain. Main Outcome Measures A review of the definition, prevalence, impact, and pathophysiological factors involved in vulvodynia. Results Vulvodynia is a prevalent and highly impactful genital pain condition. Numerous factors have been implicated in its development and maintenance. Conclusion What is becoming increasingly apparent is that it likely represents the end point of different factors that can differ from patient to patient. Longitudinal research is needed to shed light on risk factors involved in the expression of vulvodynia, as well as in potential subgroups of affected patients, in order to develop an empirically supported treatment algorithm.

Introduction Lichen sclerosus (LS) is a chronic inflammatory dermatosis, usually affecting the anogenital skin in women. This chronic inflammation can cause scarring of genitalia including narrowing of the introitus and phimosis of the clitoris. These architectural changes can lead to recurrent tearing during intercourse (vulvar granuloma fissuratum) and decreased clitoral sensation. Surgical correction of vulvar granuloma fissuratum (VGF) and clitoral phimosis can be performed, but there is little data on the patient satisfaction and complications following these surgical procedures. Aim To evaluate patient experience and outcomes in women undergoing surgical correction of scarring caused by anogenital LS. Methods A retrospective chart review of patients at a vulvar disorders clinic was performed to identify women who had undergone surgical correction of clitoral phimosis or lysis of vulvar adhesions for VGF due to LS. Twenty-eight women were contacted via telephone between 4 and 130 months postoperatively. An eight-question survey was used to determine patient experience and outcomes. Main Outcome Measures All participants completed an eight-question survey to evaluate patient satisfaction with the surgery, effects on clitoral sensation, orgasm and pain with intercourse, postoperative symptoms or complications, and the presence of recurrent vulvar scarring. Results Participants reported that they were either very satisfied (44%) or satisfied (40%) with the procedure. Of the women who experienced decreased clitoral sensation prior to surgery, 75% endorsed increased clitoral sensitivity postoperatively. Of the women who had dyspareunia prior to surgery, the majority of women reported having pain-free sex (33%) or improved but not completely pain-free sex (58%) after surgery. There were no complications or symptoms made worse by the surgical procedures. Conclusions This study shows high patient satisfaction and low complication risk associated with surgical correction of clitoral phimosis and lysis of vulvar adhesions for VGF caused by LS. Patients reported improvement in clitoral sensation and ability to achieve orgasm, as well as decreased dyspareunia. Surgical correction of vulvar scarring is a viable option to restore vulvar anatomy and sexual function in appropriate candidates with anogenital LS.

Abstract Desquamative inflammatory vaginitis is a poorly understood chronic vaginitis with an unknown etiology. Symptoms of desquamative inflammatory vaginitis include copious yellowish discharge, vulvovaginal discomfort, and dyspareunia. Cervical ectropion, the presence of glandular columnar cells on the ectocervix, has not been reported as a cause of desquamative inflammatory vaginitis. Although cervical ectropion can be a normal clinical finding, it has been reported to cause leukorrhea, metrorrhagia, dyspareunia, and vulvovaginal irritation. Patients with cervical ectropion and desquamative inflammatory vaginitis are frequently misdiagnosed with candidiasis or bacterial vaginosis and repeatedly treated without resolution of symptoms. We report the case of a 34-year-old woman with a 4-year history of profuse yellowish discharge and dyspareunia. Upon presentation, her symptoms and laboratory results met the criteria for desquamative inflammatory vaginitis, but the standard treatments did not provide long-lasting relief. As a last resort, cryotherapy (cryosurgery) of her cervix was performed for treatment of her cervical ectropion, which provided complete resolution of her symptoms. Mitchell L, King M, Brillhart H, Goldstein A. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Sex Med 2017;5:e212–e214.

Genital pain frequently causes sexual dysfunction and psychological distress that can impact every aspect of a woman’s life. When conservative medical treatments do not adequately treat the genital pain, surgical procedures have the potential to significantly decrease the pain. The following review examines surgical procedures currently being used to treat pudendal neuralgia, scarring from lichen sclerosus, and provoked vestibulodynia. In addition, a diagnostic algorithm is included that can be used to identify specific causes of genital pain and to determining when surgery is an appropriate treatment option.

Introduction Persistent genital arousal disorder (PGAD) is an intrusive and unremitting disorder for which several possible etiologies and treatments have been suggested. Aim To describe a woman who developed PGAD in association with a periclitoral mass, a potential physical cause of the disorder that has not been previously described in the medical literature. Methods A postmenopausal woman presented with 6 months of persistent, unrelenting genital arousal and clitoral pain that was unrelated to sexual stimuli. Careful examination revealed a tender, firm, mobile, left-sided mass that appeared to compress the dorsal nerve of the clitoris. Results Complete excision of the mass resulted in full resolution of her symptoms over several weeks. Conclusion Localized causes of persistent genital arousal, though rare, should be included in the differential diagnosis PGAD as detection and treatment can lead to a complete recovery. Bedell S, Goldstein AT, and Burrows L. A periclitoral mass as a cause of persistent genital arousal disorder. J Sex Med 2014;11:136-139.

Introduction Hypermobility-type Ehlers–Danlos syndrome (EDS), an often-missed diagnosis with the potential for serious sequelae, may have a variety of uncommon presentations, some of which may be gynecologic. Aim The aim of this case report is to present two cases of profound labial edema associated with intercourse as a presenting symptom of hypermobility-type EDS. Methods A 25-year-old female presented with severe labia minora swelling and bladder pressure associated with intercourse, in addition to persistent genital arousal. History revealed easy bruising, joint pain, and family history of aneurysm. A 22-year-old female presented with intermittent profound labial swelling for 6 years, associated with sensitivity and pain with intercourse. The patient has a history of joint pain and easy bruising, as well a sister with joint hypermobility and unexplained lymphedema. The presenting symptom of profound labial edema led to the diagnosis of hypermobility-type EDS. Results Patients with hypermobility syndrome exhibit an increased ratio of type III collagen to type I collagen, causing tissue laxity and venous insufficiency. Abnormal collagen may lead to gynecologic manifestations, including unexplained profound labial edema, pelvic organ prolapse in the absence of risk factors, and possibly persistent genital arousal. Conclusions This case report highlights the need for further research to determine incidence of labial edema in hypermobility-type EDS and to further elucidate a potential correlation between profound labial edema and collagen disorders. Krapf JM and Goldstein AT. Two case presentations of profound labial edema as a presenting symptom of hypermobility-type Ehlers–Danlos syndrome. J Sex Med 2013;10:2347–2350.

Introduction. Combined hormonal contraceptives (CHCs) use is becoming an increasingly recognized causes of vestibulodynia. Aim. This study aims to describe pre- and posttreatment vestibular pain, sex hormone binding globulin (SHBG), and calculated free testosterone levels in women undergoing treatment for vestibulodynia. Methods. This was a chart review of 50 premenopausal women who presented with vestibular pain while currently using CHCs. Pre- and posttreatment vestibular pain, SHBG, and calculated free testosterone levels were assessed. Results. There was a statistically significant improvement in posttreatment vestibular pain scores (P = 0.001), SHBG (P = 0.001), and calculated free testosterone (P = 0.001) levels from baseline. Conclusion. Women with vestibulodynia that began while on CHC may effectively be treated by discontinuing the CHC combined with the application topical hormone therapy. Symptomatic improvement is accompanied by normalization of calculated free testosterone and SHBG values.

Introduction Current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) definitions of sexual dysfunction do not identify all sexual problems experienced clinically by women and are not necessarily applicable for biologic or biopsychosocial management of female sexual dysfunction. A unified nomenclature system enables clinicians, researchers, and regulatory agencies to use the same language and criteria for determining clinical end points, assessing research results, and managing patients. Aim To develop nomenclature with classification systems for female sexual desire, arousal, and orgasm disorders with definitions pertinent to clinicians and researchers from multiple specialties who contribute to the field of sexual medicine. Methods Key national and international opinion leaders diverse in gender, geography, and areas of expertise met for 2 days to discuss and agree to definitions of female sexual desire, arousal, and orgasm disorders and persistent genital arousal disorder. The attendees consisted of 10 psychiatrists and psychologists; 12 health care providers in specialties such as gynecology, internal medicine, and sexual medicine; three basic scientists; and one sexuality educator, representing an array of societies working within the various areas of sexual function and dysfunction. Main Outcome Measure A unified set of definitions was developed and accepted for use by the International Society for the Study of Women’s Sexual Health (ISSWSH) and members of other stakeholder societies participating in the consensus meeting. Results Current DSM-5 definitions, in particular elimination of desire and arousal disorders as separate diagnoses and lack of definitions of other specific disorders, were adapted to create ISSWSH consensus nomenclature for distressing sexual dysfunctions. The ISSWSH definitions include hypoactive sexual desire disorder, female genital arousal disorder, persistent genital arousal disorder, female orgasmic disorder, pleasure dissociative orgasm disorder, and female orgasmic illness syndrome. Conclusion Definitions for female sexual dysfunctions that reflect current science provide useful nomenclature for current and future management of women with sexual disorders and development of new therapies.

FIGURE 1 Biopsy of the skin is the most important diagnostic test for the evaluation of inflammatory dermatoses of the vulva such as lichen sclerosus and lichen simplex chronicus. Punch biopsy is the primary technique to obtain full thickness specimens that can sent for histologic evaluation by a dermatopathologist [1]. It is key to distinguish normal from abnormal. This figure represents a photo of a normal-appearing vulva, a histologic section of normal vulvar skin, and an illustration of the various layers within skin. Normal vulva Normal histology of vulvar region

Introduction Vulvodynia is increasingly recognized as a cause of sexual pain. Aim The goal of this Continuing Medical Education article was to provide a comprehensive review of vulvodynia including terminology, possible etiologies, and offer treatment options. Methods A Medline search was conducted using several terms related to and including the terms vulvodynia, vulvar vestibulitis, vestibulodynia, and pudendal neuralgia. Results A thorough review of vulvodynia. Conclusion Vulvodynia most likely represents several disorders without an identifiable cause in many cases. The management of these patients requires a sensitive provider who can coordinate a multidisciplinary approach to their care. Despite the lack of large-scale, placebo-controlled trials, several new treatment options exist. Goldstein AT, and Burrows L. Vulvodynia.

A B S T R A C T Introduction. Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the International Society for the Study of Women's Sexual Medicine. At the suggestion of a board member, it was determined that this discussion might of interest to journal readers in the form of a published controversy. Methods. Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had been involved in the earlier online discussion, were invited to submit evidence-based opinions on the topic. Main Outcome Measure. To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Results. Goodman believes that patients should make their own decisions. Bachmann further states that, while that is a woman's right, she should be counseled first, because variations in looks of the vulvar region are normal. Johnson furthers this thought, discussing the requirement for counseling before performing reinfibulation surgery on victims of female genital cutting. Fourcroy emphasizes the need to base surgical procedures on safety and efficacy in the long term, and not merely opportunity at the moment. Goldstein and Goldstein state that, based on the four principles of ethical practice of medicine, vulvar plastic surgery is not always ethical, but not always unethical. Sklar pursues this thought further, pointing out specific examples in regard to the principles of ethics. Conclusion. Vulvar plastic surgery may be warranted only after counseling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery. Goodman MP, Bachmann G, Johnson C, Fourcroy JL, Goldstein A, Goldstein G, and Sklar S. Is elective vulvar plastic surgery ever warranted, and what screening should be done preoperatively? J Sex Med 2007;4:269-276.

Introduction Vulvodynia constitutes a highly prevalent form of sexual pain in women, and current information regarding its assessment and treatment is needed. Aim To update the scientific evidence published in 2010, from the Third International Consultation on Sexual Medicine, pertaining to the assessment and treatment of women's sexual pain. Methods An expert committee, as part of the Fourth International Consultation on Sexual Medicine, was comprised of researchers and clinicians from biological and social science disciplines for the review of the scientific evidence on the assessment and treatment of women's genital pain. Main Outcome Measures A review of assessment and treatment strategies involved in vulvodynia. Results We recommend the following treatments for the management of vulvodynia: psychological interventions, pelvic floor physical therapy, and vestibulectomy (for provoked vestibulodynia). We also support the use of multidisciplinary treatment approaches for the management of vulvodynia; however, more studies are needed to determine which components are most important. We recommend waiting for more empirical evidence before recommending alternative treatment options, anti-inflammatory agents, hormonal agents, and anticonvulsant medications. Although we do not recommend lidocaine, topical corticosteroids, or antidepressant medication for the management of vulvodynia, we suggest that capsaicin, botulinum toxin, and interferon be considered second-line avenues and that their recommendation be revisited once further research is conducted. Conclusion A comprehensive assessment is needed to understand the pain experience of women presenting with vulvodynia. In addition, treatment typically progresses from less invasive to more invasive, and several treatment options are worth pursuing.

Introduction. Vulvar vestibulitis syndrome (VVS) is the most common pathology in women with sexual pain. Surgery for VVS was first described in 1981. Despite apparently high surgical success rates, most review articles suggest that surgery should be used only "as a last resort." Risks of complications such as bleeding, scarring, and recurrence of symptoms are often used to justify these cautionary statements. However, there are little data in the peer-reviewed literature to justify this cautionary statement. Aims. To determine patient satisfaction with vulvar vestibulectomy for VVS and the rate of complications with this procedure. Methods. Women who underwent a complete vulvar vestibulectomy with vaginal advancement by one of three different surgeons were contacted via telephone by an independent researcher between 12 and 72 months after surgery. Main Outcome Measures. The primary outcome measurement of surgical success was overall patient satisfaction with surgery. Additional secondary outcome measurements included improvement in dyspareunia, changes in coital frequency, and occurrence of surgical complications. Results. In total, 134 women underwent surgery in a 5-year period. An independent research assistant was able to contact 106 women, and 104 agreed to participate in the study. Mean duration since surgery was 26 months. A total of 97 women (93%) were satisfied, or very satisfied, with the outcome of their surgery. Only three patients (3%) reported persistently worse symptoms after surgery and only seven (7%) reported permanent recurrence of any symptoms after surgery. Prior to surgery, 72% of the women were completely apareunic; however, after surgery, only 11% were unable to have intercourse. Discussion. In this cohort of patients, there was a high degree of satisfaction with surgery for VVS. In addition, the risks of complications with this procedure were low, and most complications were transient and the risk of recurrence after surgery was also found to be low. Goldstein AT, Klingman D, Christopher K, Johnson C, and Marinoff SC. Surgical treatment of vulvar vestibulitis syndrome: Outcome assessment derived from a postoperative questionnaire. J Sex Med 2006;3:923-931.

Introduction Provoked vestibulodynia is the most common cause of sexual pain in premenopausal women. Vulvar vestibulectomy has been shown to be an effective treatment. Aim To determine the optimum route of parturition in women who become pregnant after vulvar vestibulectomy. Methods All women who underwent a complete vulvar vestibulectomy by one of four surgeons were contacted between 12 and 72 months after surgery. For all women who had a term pregnancy and subsequent delivery, the research assistant abstracted data from the charts. Descriptive statistics were applied. Main Outcome Measures The number of women who underwent a delivery after a vestibulectomy, mode of delivery, and rate of perineal lacerations. Results Of 109 women, 44 (40%) had undergone at least one term pregnancy and delivery; 23 (52%) were vaginal, and 21 (48%) were cesarean deliveries. Of the vaginal deliveries, 11 (48%) were over an intact perineum. Three (13%) women had a midline episiotomy, none of which extended into third or fourth degree lacerations and one woman (4.4%) sustained a spontaneous fourth degree perineal laceration. Conclusions Vaginal delivery after vulvar vestibulectomy appears to be a safe option, with no increased perineal morbidity above the general population. Furthermore, it is not an indication for a cesarean delivery. Burrows LJ, Sloane M, Davis G, Heller DS, Brooks J, and Goldstein AT. Parturition after vestibulectomy. J Sex Med 2011;8:303–305.

Aim Women who developed vestibulodynia (vulvar vestibulitis) while taking combined hormonal contraceptives (CHCs) and a control group of women were tested for polymorphisms of the gene coding for the androgen receptor (AR) that is located on the X chromosome. Study Design DNA from 30 women who developed vestibulodynia while taking CHCs and 17 control women were tested for the number of cytosine–adenine–guanine (CAG) trinucleotide repeats in the AR. In addition, serum-free testosterone was tested in both groups. Results The mean number of CAG repeats in the study group was significantly greater than the control group (22.05 ± 2.98 vs. 20.61 ± 2.19, respectively; P = 0.025). This significant difference persisted when analyzing the CAG repeats from the longer allele from each subject. Among those who were taking drospirenone-containing CHCs, the mean calculated free testosterone was 0.189 ± 0.115 ng/dL in the study group and 0.127 ± 0.054 ng/dL in the control group, all of whom were taking drospirenone-containing CHCs ( P = 0.042). Conclusion In the study cohort, women who developed vestibulodynia while taking CHCs are more likely to have longer CAG repeats in the AR than women who took the same type of CHC but did not develop vestibulodynia. We speculate that the risk of developing CHC-induced vestibulodynia may be due to lowered free testosterone combined with an inefficient AR that predisposes women to vestibular pain. Goldtein AT, Belkin ZR, Krapf JM, Song W, Khera M, Jutrzonka SL, Kim NN, Burrows LJ, and Goldstein I. Polymorphisms of the androgen receptor gene and hormonal contraceptive induced provoked vestibulodynia. J Sex Med 2014;11:2764–2771.

Introduction. Hormonal contraceptives can influence female sexual function. Aim. The goal of this article was to provide a comprehensive review of the effects that various hormonal contra- ceptives may have on female sexual function. Methods. A Medline search was conducted using several terms related to and including the terms contraception, oral contraceptive, female sexual function, dyspareunia, libido, and sexual desire. Results. A thorough review of the effects of hormonal contraceptives on female sexual function. Conclusions. The sexual side effects of hormonal contraceptives are not well studied, particularly with regard to impact on libido. There appears to be mixed effects on libido, with a small percentage of women experiencing an increase or a decrease, and the majority being unaffected. Healthcare providers must be aware that hormonal contraceptive can have negative effects on female sexuality so they can counsel and care for their patients appropri- ately. Burrows LJ, Basha M, and Goldstein AT. The effects of hormonal contraceptives on female sexuality: A review. J Sex Med 2012;9:2213-2223.

Introduction Women with lichen sclerosus (LS) are more likely to have dyspareunia, decreased orgasm, and decreased coital frequency as compared to unaffected women. It is unknown whether standard medical therapy to treat LS results in improved sexual functioning. Aims To describe sexual function in women with LS and to assess if LS‐associated sexual dysfunction decreases after appropriate medical therapy. Methods Women enrolled in a double‐blind trial 12‐week trial comparing clobetasol vs. pimecrolimus for the treatment of LS were administered the Female Sexual Distress Scale (FSDS) upon enrollment and at the end of the trial. The difference in the total score on the FSDS between the two groups before and after treatment was assessed with a paired t ‐test. Main Outcome Measures The change in mean FSDS score from baseline to 12 weeks. Results A total of 31 out of 36 enrolled women had adequate treatment of LS as determined by a dermatopathologist's evaluation of pre and post‐treatment biopsy specimens. The mean baseline FSDS score for the clobetasol group was 29 and, post‐treatment, it was 15 ( P = 0.001). In the pimecrolimus group, the mean baseline FSDS score was 27 and, post–treatment, it was 21 ( P = 0.001). Conclusions Despite adequate treatment, women with LS continue to have significant sexual dysfunction as assessed by the FSDS. Burrows LJ, Creasey A, and Goldstein AT. The treatment of vulvar lichen sclerosus and female sexual dysfunction.

Introduction Although approximately 40% of women report female sexual problems—and particularly sexual desire disorders, there are numerous practical, professional, and personal barriers to their diagnosis and management by treating clinicians. Aim To identify practice patterns, perceptions, and barriers to the diagnosis and management of female sexual problems among U.S. practicing primary care physicians (PCPs) and obstetrician/gynecologists (OB/GYNs). Methods A random sample of practicing U.S. PCPs and OB/GYNs were sent a case-vignette survey by e-mail and fax. Response to the survey was considered consent. A regression model was analyzed to assess predictors of confidence. Main Outcome Measure Frequency and variability in diagnostic tests ordered and treatment recommendations provided for a patient with diminished sexual desire. Percent of physicians who reported they were confident in treating hypoactive sexual desire disorder (HSDD) and percent who reported significant barriers to initiating a dialogue about sexual health with female patients. Results A total of 505 responses were analyzed (8.8% response rate). Of respondents, 21% of OB/GYNs and 38% of PCPs stated they were not at all confident in treating HSDD. The majority of physicians would order a thyroid panel (PCP = 63%, OB/GYN = 53%) to assess a patient's diminished desire and recommended counseling and stress management to treat a patient with sexual complaints (PCP = 48%, OB/GYN = 54%). Regression results identified time constraints, the perceived lack of effective therapies, perceptions regarding patient-physician gender discordance, years in practice, number of patients seen per week, and perceptions regarding continuing medical education and practice experience as significant and independent predictors of confidence in treating HSDD patients. Conclusions Discussion of sexual health is difficult, but there are independent predictors of confidence in treating patients with decreased desire. Abdolrasulnia M, Shewchuk RM, Roepke N, Granstaff US, Dean J, Foster JA, Goldstein AT, and Casebeer L. Management of female sexual problems: Perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists.

AimTo describe the clinical course of a young woman who developed vestibulodynia with introital dyspareunia while on oral contraceptive (OCs) and to provide a possible explanation for the etiology of her symptoms as well as her recovery after treatment.MethodsA single case is presented including subjective reporting, laboratory evaluation, and quantitative sensory testing.ResultsAfter topical hormonal therapy, the patient reported resolution of her dyspareunia and and her laboratory values normalized.

Introduction. Dermatologic diseases of the vulva may cause dyspareunia. These disorders may be overlooked by gynecologists and urologists because of lack of residency training experience. Dermatologists who are most familiar with these diseases are infrequently trained in vulvovaginal examination. As such, these disorders are often improp- erly diagnosed and treated. Aim. To describe the presentation and management of the major vulvar dermatoses including irritant and allergic contact dermatitis, lichen sclerosus, lichen simplex chronicus, and lichen planus. Main Outcome Measure. Data from a peer review literature search on the topic of vulvar dermatoses. Methods. The literature for this review article was obtained through a Medline search. Appropriate dermatology textbooks were utilized for additional information. Results. A comprehensive survey of the vulvar dermatoses. Conclusion. Vulvar dermatoses must be considered a part of the differential diagnosis of any woman with a sexual pain disorder. As such, healthcare providers who evaluate and treat women with dyspareunia must become familiar with the most common dermatologic disorders of the vulva. Burrows LJ, Shaw HA, and Goldstein AT. The vulvar dermatoses. J Sex Med 2008;5:276-283.