International Journal of STD & AIDS 2003; 14: 796–799
ORIGINAL RESEARCH ARTICLE
Longstanding vulval problems and entry dyspareunia among STD-clinic visitors in Oslo — results from a cross-sectional study Karin Edgardh MD PhD1 and Michael Abdelnoor MPH PhD2 1Olaaklinikken,
Grensen 5–7, NO-0159 Oslo, and 2The Centre for Clinical Research, Section for Epidemiology, Ulleva°l University Hospital, Oslo, Norway
Summary: An increasing number of women with vulval problems and pain attend Ola® aklinikken, the centre for sexually transmitted infection (STI) in Oslo. The aim of the study was to investigate the prevalence of long-standing vulval problems and entry dyspareunia in a consecutive sample of STI-clinic visitors in Oslo. A self-administered questionnaire was distributed before and independent of the consultation. Response rate was 89.6% (502/560). Mean and median age were 25.9 and 24.0 years respectively, range 16± 65 years. Vulval soreness, burning, dryness and ® ssures present for at least three months were reported by 23.1% (116/502), entry dyspareunia by 6.9% (34/494). Independent risk factors for dyspareunia were a history of 54 treatments for vulvovaginal candidiasis during the last year, reported by 34.6%, odds ratio (OR) 4.45, 95% con® dence interval (CI) 1.81± 11.0, and a history of bacterial vaginosis, reported by 42.4%, OR 2.34, 95% CI 1.11± 4.92. Contraceptive methods, hygienic habits, a history of STIs, depression or sexual abuse were factors unrelated to longstanding symptoms. Investigation with regard to longstanding vulval problems and entry dyspareunia is required for a certain group of sexually transmitted disease-clinic visitors in Oslo, and referral to a special service for vulva patients would be bene® cial for selected patients. Keywords: vulvodynia, dyspareunia, vulvovaginal candidiasis, bacterial vaginosis
Introduction Women with longstanding vulval problems and pain consult general practitioners as well as gynaecologists and dermatologists, but may ® nd it dif® cult to locate experienced caregivers. Although vulval problems are not speci® cally related to sexually transmitted disease, venereologists and specialists in genitourinary medicine (GUM) may have an appeal to these patients by reason of `high standards, ready availability, and con® dentiality of the clinics, to which there is open access’, as pointed out by Ridley 1998 in an overview of vulvodynia1. Vulvodynia is a concept that covers chronic vulval discomfort, especially that characterized by the patient’s complaint of burning, stinging, irritation, rawness and coital pain. Many reviews have been published in the ® eld, also in journals for sexually transmitted infections (STIs)2± 4. Recently, the Medical Society for the Study of Venereal Diseases (MSSVD) published guidelines on the Correspondence to: Dr K Edgardh, Vulvaklinikken, Krinneklinikken, Rikshospitalet, 0027 Oslo, Norway E-mail:
[email protected]
management of vulval conditions5. Diagnosis relies predominantly on clinical awareness. During recent years, an increasing number of women with longstanding vulval problems have attended the Ola® aklinikken, the walk in centre for STI in Oslo. The clinic receives about 10,000 new visitors per year, and 43% are women. To meet with the needs, a special service for vulva patients was initiated in 20006. The aim of the present paper is to report the ® ndings on prevalence and characteristics of longstanding vulval symptoms in a consecutive sample of STI-clinic visitors, with special focus on entry dyspareunia.
Materials and methods A cross-sectional questionnaire-based study was performed among consecutive female patients attending the Ola® aklinikken during April to May 2002. Patients visiting the vulva clinic were excluded from participation. Visitors were issued with a self-administered questionnaire to complete before their consultation. Distribution was handled by of® ce staff upon the patient’s registration. The questionnaire comprised 52 multiple choice questions addressing gynaecological history,
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Edgardh and Abdelnoor. Vulval pain prevalence in STD clinics
contraception and genital hygiene, prior genital infections and STIs, sexual practice, depression and sexual abuse, and current vulval symptoms with a duration exceeding three months, with focus on entry dyspareunia. Participation was voluntary, anonymous and not connected to the consultation. Ethical approval was not required for conducting the study according to the local ethics committee, but the committee approved of publication.
Power calculation and statistical methods According to the investigator’s clinical estimation, the prevalence of entry dyspareunia would be approximately 6%. If a 3% variation was accepted, a sample size of approximately 380 patients would permit a 95% con® dence interval (CI) to contain the true expected frequency of dyspareunia. In order to prevent inaccuracy due to a high rate of nonresponders, 560 questionnaires were distributed. Data were entered into EpiData, and EpiInfo and the Statistical Package for the Social Sciences were used for statistical analyses7. Univariate analysis was performed with w2 tables and Fisher’s exact tests. Independent risk factors for entry dyspareunia were evaluated using the multivariate logistic model with a manual backwards elimination procedure8.
Results Patient characteristics Of the 560 questionnaires 502 were completed, response rate 89.6%. The respondents’ mean and median age were 25.9 and 24.0 years respectively, range 16± 65 years. Most respondents had a steady male partner, 59.0% (298/505), and 4.2% (21/505) were married. Allergy and/or atopic symptoms were reported by 35.8% (174/486). A high number of women, 28.4% (150/503), had seen a doctor due to depression, and a total of 17.2% (91/500) had experienced sexual abuse. The majority, 97.6% (486/498), had an overall positive experience of sexual relations. Use of oral contraception was reported by 66.1% (220/333), and 34.3% (74/216) were longtime users with a treatment period of ® ve years or more. Thirty-three percent (166/503) had been pregnant, and 14.9% (75/502) had given birth. Most of the respondents, 56.2% (287/511), came to the clinic due to genital symptoms. Asymptomatic patients came for a STI check up, for a partner control, or for contraceptive counselling.
Genital infections A history of genital chlamydial infection was reported by 33.5% (177/497), condylomas by 26.7% (141/471), and genital herpes by 10.3% (54/475). Any episode of candidiasis was reported by 67.2% (355/492), and bacterial vaginosis by
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24.8% (131/479). Treatment for candidiasis at least four times during the last year was reported by 10.9% (38/350), thus ful® lling the criteria for recurrent vulvovaginal candidiasis presumed a correct diagnosis. Risk factors for frequent treatment with antiyeast agents were atopic manifestations, reported by 62.2% (23/37) patients with atopic manifestations compared to 35.9% (110/306) without, Pˆ 0.004, relative risk (RR) 2.59, 95% CI 1.38± 4.86. A second risk factor was use of oral antibiotics twice or more during the last year, reported by 42.1% (16/38) of frequent antiyeast users compared with 13.8% (62/490) non-users, P50.0001, RR 4.20, 95% CI 2.31± 7.63. Cunnilingus was not a risk factor for a history of candida, or frequent use of antifungal treatment (data not shown).
Longstanding vulval symptoms and entry dyspareunia Ongoing vulval problems with burning, post-coital soreness, dryness and ® ssures, with a duration of at least three months, were reported by 23.1% (116/ 502). Symptom duration exceeded one year for 29.4% (32/109), 68.4% (78/114) had seen a doctor due to the symptoms, and 26.3% (30/114) had been doctor-shopping. There was no difference between symptomatic and asymptomatic patients with regard to having seen a doctor due to depression or to a history of sexual abuse (data not shown). A variable for entry dyspareunia was created, comprising pain at vestibular touch and vaginal entry, penile or upon tampon insertion. According to this de® nition, 6.9% (34/494) of the patients had suffered from entry dyspareunia for three months or more. Factors related to longstanding super® cial dyspareunia are presented in Table 1. Women with entry dyspareunia more often abstained from intercourse, in spite of having a steady partner. Table 2 shows the results of a multivariate logistic regression analysis. Three factors were independently associated with super® cial dyspareunia: women with a history of bacterial vaginosis had a twofold risk of reporting dyspareunia, while women with frequent treatment of candidiasis had a ® ve-fold increased risk of presenting with dyspareunia compared with women without this history. A history of pregnancy, but not con® nement, was related to a lower risk of reporting dyspareunia, in spite of no relation found with regard to choice of contraceptive method among parous and non-parous respondents.
Discussion The present study was designed not to interfere with busy everyday clinical routines, and the questionnaire could be answered in a few minutes. The response rate of 89.6% was satisfactory, and
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International Journal of STD & AIDS Volume 14 December 2003
Table 1. Longstanding entry dyspareunia and background factors
Mean age Steady partner Reason for visit No suspicion of STI Contraception Condoms Oral contraception (OC) OC55 years Pregnancy Ever pregnant Given birth Genital hygiene Regular pubic shaving ‘Intime’ soap Regular use of panty liners History of genital infections Chlamydia Condylomas Herpes Bacterial vaginosis Treatment for candidiasis 54 times last year Oral antibiotics 52 times last year Sexual experience General positive experience of sex At present, no intercourse
Dyspareunia n ˆ34 %
No dyspareunia nˆ 494 %
P-values*
RR
95% CI
23.8 24/33
72.7
25.3 295/472
62.5
0.268
1.56
0.74–3.27
13/33
39.4
67/478
14.0
0.0005
3.50
1.82–6.75
4/27 20/27 8/20
14.8 74.1 40.0
75/306 200/306 66/196
24.5 65.4 33.7
0.347 0.405 0.624
0.56 1.47 1.28
0.19–1.57 0.64–3.37 0.55–2.99
6/34 3/34
17.6 8.8
160/469 71/468
34.1 15.2
0.058 0.335
0.44 0.51
0.18–1.03 0.16–1.63
23/32 12/33 14/19
71.9 36.4 73.7
329/458 153/464 126/456
71.8 33.0 27.6
1.000 0.704 0.075
1.00 0.87 1.84
0.48–2.11 0.44–1.72 0.95–3.56
15/33 7/30 7/32 14/33 9/26
45.5 23.3 21.9 42.4 34.6
162/464 134/441 47/443 117/446 29/324
34.9 30.4 10.6 26.2 9.0
0.259 0.538 0.076 0.066 0.001
1.51 0.71 2.18 1.96 4.35
0.78–2.92 0.31–1.62 0.99–4.81 1.01–3.79 2.09–9.06
11/33
33.3
67/454
14.8
0.011
2.62
1.33–5.19
31/32 3/33
96.9 9.1
455/466 4/468
97.6 0.9
0.554 0.010
0.77 7.06
0.11–5.16 2.80–17.77
STIˆ sexually transmitted infection *Fisher’s exact test
few answers were missing. The questionnaire is unvalidated, but can be compared with the questionnaires published by Swedish researchers Bohm-Starke and Danielsson in their studies on the vulvar vestibulitis syndrome9,10. Danielsson’s population-based Swedish survey comprised 3017 women aged 20± 60 years, participating in the national screening programme for cervical cancer11. A history of prolonged and severe dyspareunia was higher the younger the respondent, with a prevalence of 13% among women aged 20± 29 years. The prevalence of vulvodynia and dyspareunia among STD-clinic visitors remains less investigated than among patients presenting to gynaecologists and dermatologists. An assumption is that a woman attending a GUM-clinic is not supposed to have problems resulting in limitations on her sexual relationship, apart from any discomfort related to a speci® c STI. Patients may be reluctant Table 2. Independent risk factors for superficial dyspareunia using the multivariate logistic model Risk factor
Level
OR
Treatment for candidiasis yes/no 5.51 54 times last year History of bacterial yes/no 2.34 vaginosis Ever pregnant yes/no 0.61
95% CI
P-values
2.30–13.17 0.0001 1.11–4.92
0.025
0.36–1.0
0.050
to report dyspareunia spontaneously, as pointed out by Davis and Hutchinson in their overview of clinical management of vulvodynia12. However, in a study by Denbow and Byrne among 150 consecutive patients in a GUM-clinic population in London, 13.3% reported vulval pain13. Candidiasis was the most prevalent diagnosis, and two women were diagnosed with the vulvar vestibulitis syndrome. Sullivan et al. reported from a multidisciplinary vulva clinic in London, that despite having genitourinary symptoms, less than half the patients had been tested for infection prior to being referred to the vulva clinic14. Of 135 referred vulva patients, 34% were diagnosed with a genitourinary infection, mostly vulvovaginal candidiasis. Consequently, it was pointed out that there is a signi® cant role for genitourinary services in the diagnosis, management and ongoing care of patients in a vulva clinic. Hopefully, with proper history-taking, and through assessment of genital infections (not only speci® c STIs) in patients presenting at GUM-clinics, doctor’s delay could be reduced in the management of patients with vulvodynia. Recurrent vulvovaginal candidiasis and vulvar vestibulitis constitute two major causes of entry dyspareunia in young women. These two conditions are interrelated, as described by Friedrich in his article from 1987, introducing the vulvar vestibulitis syndrome15, and later by e.g. Sarma et al.16 The interactive mechanisms remain unclear.
Edgardh and Abdelnoor. Vulval pain prevalence in STD clinics
However, a history of frequent antifungal treatment may have different causes. A recurrent vulvovaginal candidiasis can be the true cause, with insuf® cient treatment duration according to accepted recommendations and guidelines 17± 19. Furthermore, unintended misuse of antiyeast agents occurs, as has been reported by Ferris et al.20. Among 95 women purchasing over the counter-agents for self-diagnosed vulvovaginal candidiasis, only 33.7% had the actual diagnosis at clinical examination. Women with a previous clinically based diagnosis of vulvovaginal candidiasis were not more accurate in their selfdiagnosis. Possibly, skilled management of repeated episodes of recurrent vulvovaginal candidiasis could prevent a certain number of longstanding entry dyspareunia that may turn into vestibulitis. Today, vulvar vestibulitis is recognized as a pain syndrome, and not an in¯ ammatory condition. The histopathology and pathophysiology of vulvar vestibulitis is described by WestroÈm, Lundqvist and Bohm-Starke21± 24. A referral to a dedicated vulva clinic is bene® cial for patients with vulvar vestibulitis, preferably with access to psychosexual counselling. Finally, regimens for the general management of vulval conditions include the avoidance of contact with irritants e.g. soap, shampoo and bubble bath, and tight-® tting garments which may irritate the area2. In the present study, no difference was found between symptomatic and asymptomatic patients with regard to genital hygiene.
Conclusion Assessment of patients with vulval pain and dyspareunia relies predominantly on clinical awareness, as pointed out by Edwards and Wojnarowska 19983. Assessment may be easy, but management is more dif® cult and time-consuming. However, careful management of candidiasis and bacterial vaginosis among GUM-clinic visitors, and cautious use of antifungal agents and oral antibiotics, may hopefully contribute to a decreased risk for longstanding vulval problems and entry dyspareunia in young women. A referral to a dedicated vulva clinic may be bene® cial for selected patients, and patients with vulva pain syndromes. Acknowledgement: The study was supported by a post-doctoral grant from The Centre for Clinical Research, Section for Epidemiology, UllevaÊl University Hospital, Oslo.
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(Accepted 20 November 2002)
