links
The interaction of the vaginal microbiome with other infections and disease is a subject of current interest. The rate of clearance of human papillomavirus (HPV) has been linked to changes in the microbiome. Women with lactobacilli clusters of L. gasseri and L. iners have more rapid clearance of vaginal HPV, whereas it can be slower with the group who have reduced lactobacilli and increased Atopobium species [23]. There is also interest in the role of the microbiome in cervical cancer [24].
If significant links are established, then this may have therapeutic implications for the use of probiotics [25]. These are taken orally and are used in a variety of conditions. They usually contain a combination of lactobacilli and Bifidobacterium species [26].
References
1 1 Brown, C.J., Wong, M., Davis, C.C. et al. Preliminary characterization of the normal microbiota of the human vulva using cultivation‐independent methods. J Med Microbiol. 2007 Feb; 56(Pt 2): 271–276.
2 2 Aly, R., Britz, M.B. and Maibach, H.I. Quantitative microbiology of human vulva. Br J Dermatol. 1979 Oct; 101(4): 445–448.
3 11 Hickey, R.J., Zhou, X., Settles, M.L. et al. Vaginal microbiota of adolescent girls prior to the onset of menarche resemble those of reproductive‐age women. mBio. 2015 Mar 24; 6(2): e00097–15.
4 15 Ravel, J., Gajer, P., Abdo, Z. et al. Vaginal microbiome of reproductive‐age women. Proc Natl Acad Sci U S A. 2011 Mar 15; 108(Suppl. 1): 4680–4687.
5 19 Fettweis, J.M., Serrano, M.G., Brooks, J.P. et al. The vaginal microbiome and preterm birth. Nat Med. 2019 Jun; 25(6): 1012–1021.
6 21 Witkin, S.S. The vaginal microbiome, vaginal anti‐microbial defence mechanisms and the clinical challenge of reducing infection‐related preterm birth. BJOG. 2015 Jan; 122(2): 213–218.
7 25 Griffin, C. Probiotics in obstetrics and gynaecology. Aust N Z J Obstet Gynaecol. 2015 Jun; 55(3): 201–209.
5 The Vulval Clinic, History, and Examination
Fiona M. Lewis
CHAPTER MENU
The consultation History Examination History and examination in children Documentation Management
Helpful websites for patient information
In recent years, patients have become much more aware of their own health and better informed about their disease, diagnosis, and management. However, attitudes to vulvovaginal disease continue to be very much affected by the contemporary social and cultural background. Despite campaigns to educate women about vulval self‐examination, encouraging them to talk openly about their symptoms and to seek help early, there is still a certain amount of stigma attached to genital disease. Women are often embarrassed to discuss vulval problems [1] and often fear their symptoms may be due to a sexually transmitted infection. Trotula in the eleventh century said ‘since these organs happen to be in a retired location, women on account of modesty and the fragility and delicacy of the state of these parts dare not reveal the difficulties of their sickness to a male doctor’, and this is still true for some women today. The sex of the patient and the healthcare professional has a big influence on patient preference when it comes to genital examination, and some women do still often wish to be seen by a female doctor. Interestingly, those with vulval problems are more likely to be referred to a specialised vulval clinic if seen by a female general practitioner [2].
However, not only does the patient find seeking medical advice about vulval symptoms challenging, but many clinicians also find it difficult. Surveys of paediatric [3] and paediatric surgical trainees [4] report a lack of confidence in dealing with vulval and vaginal conditions and a need for more training. The same is true for dermatology and gynaecology trainees [5,6], where exposure to vulval teaching was very variable. When patients are referred to a vulval clinic, a diagnosis is offered in less than half the cases by the referring physician, and 27% of these were changed after the patient had been seen [7]. A questionnaire survey of fellows of the International Society for the Study of Vulval Disease (ISSVD) revealed that 29% were self‐taught [8]. The formation of international societies with members who demonstrate a specific interest in vulvovaginal disorders has helped to develop vulval disease as a sub‐specialty. This collaboration between relevant specialists aims to increase knowledge and ultimately improve care for women with these conditions. Several countries now have multidisciplinary groups that meet regularly and also organise postgraduate courses dedicated to teaching about vulval disease.
The vulval clinic
Vulval complaints are common, with 45% of general practitioners seeing more than one patient a month with recurrent symptoms [9]. Patients with vulval problems present to a variety of health professionals, including gynaecologists, dermatologists, genitourinary physicians, urologists, physiotherapists, and paediatricians. This can often lead to confusion and inappropriate management, with varying approaches according to specialty. Specific clinics dedicated to vulval and vaginal disorders provide the most appropriate setting for any patient with these symptoms to be seen. They should be run by trained medical and nursing staff, with the equipment necessary for diagnostic investigation readily available. This combined approach is a valuable resource, beneficial in management, teaching, and research.
The first vulval clinic was held at Tulane University School of Medicine, Louisiana, in 1957 [10]. The number of vulval clinics available has increased dramatically, and the benefits of such clinics have been shown [11–13]. There are published standards of care of vulval clinics in the United Kingdom [14], but audits show that there is still some way to go with full compliance [15].
There are many vulval conditions which require the input of different specialists, and multidisciplinary working is the best way of approaching this. The way that individual clinics are run can vary but should be led by adequately trained sub‐specialists who continue to develop their skills in the field. It can be helpful to hold combined clinics with other specialists present to see the patient at the same time, but it is most important to build links with other specialties who may be needed at different times to manage specific issues related to the patient’s vulval condition. A good example is that of erosive lichen planus, where complications at distant sites such as the lacrimal duct and external auditory meatus would need referral to ophthalmology and otorhinolaryngology consultants, respectively. A wide range of other specialties may need to be involved in some aspect of patient care (Figure 5.1), but this should be coordinated through the vulval clinic.
Figure 5.1 The multidisciplinary specialities that are required