History of Abuse in Women With Vulvar Pruritus, Vulvodynia, and Asymptomatic Controls Bina Cohen-Sacher, MD,1 Hope K. Haefner, MD,2 Vanessa K. Dalton, MD, MPH,2 and Mitchell B. Berger, MD, PhD2 Objective: 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. Materials and Methods: 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. Results: 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. Conclusions: Patients with vulvar pruritus and vulvodynia report similar rates of sexual and physical abuse. Key Words: vulvodynia, pruritus vulvae, sexual abuse, genital tract infections (J Lower Gen Tract Dis 2015;19: 248–252)
V
ulvar pruritus and vulvodynia are 2 of the most common vulvar diseases encountered by vulvar specialists.1–8 The etiologic factors for the development of these 2 conditions are enigmatic. Many hypotheses were suggested throughout years of research, including atopy and eczema for chronic pruritus,9 and infection, inflammation, and chronic neuropathic pain for vulvodynia.7,10–17 The role of psychologic factors and stress in the etiology of both diseases was also discussed in previous articles.18–20 There have been several studies suggesting that patients with vulvodynia are not more likely to have suffered previous sexual or physical abuse.21–23 However, no studies, to our knowledge, have looked for a possible correlation between vulvar pruritus and a past trauma of sexual or physical abuse. In this article, we compared gynecologic and general health background, and a history of physical and sexual abuse, collected from questionnaires from patients with chronic vulvar pruritus and with vulvodynia and healthy patients
1
Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel; and 2Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI Correspondence to: Bina Cohen Sacher, MD, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel. E-mail: [email protected] This research was supported by Michigan BIRCWH Career Development Program grant K12 HD001438. M.B.B. received investigator support through the National Institute of Child Health and Human Development BIRCWH Career Development Award K12 HD001438. The authors thank the University of Michigan CTSA for the use of the REDCap electronic database and for the grant support (No. UL1RR024986). The authors have declared they have no conflicts of interest. © 2015, American Society for Colposcopy and Cervical Pathology
248
presenting for routine annual gynecologic examinations. We aim to test the hypothesis that women with chronic vulvar pruritus report similar rates of past sexual and/or physical abuse as controls with vulvodynia or women presenting for routine annual examinations.
MATERIALS AND METHODS Every new patient presenting for evaluation and treatment in the University of Michigan Center for Vulvar Diseases in Ann Arbor, MI, completes a questionnaire that is de-identified. These questionnaires contain closed questions regarding their symptoms, their general medical and gynecologic history, the McGill Pain Questionnaire, and questions regarding sexuality and sexual relations. When examined at the clinic, diagnosis is made by the health care provider based on the symptoms, course of disease, and findings in the physical examination. Approval was obtained from the University of Michigan Institutional Review Board. All available completed questionnaires from patients with itchscratch (I-S) and vulvodynia (V) were included in this study. A convenience sample of 2,012 women 18 years and older, presenting for annual gynecologic examinations at the University of Michigan Obstetrics and Gynecology Clinic between March and August, were recruited as healthy controls. These women completed a subset of questions (relevant for this study) from the Center for Vulvar Diseases New Patient Questionnaire. Responses from the questionnaires were entered into electronic databases using REDCap and exported for analysis in SPSS Version 19.0 (SPSS, Inc., IBM Corporation, Armonk, NY). Appropriate standard descriptive statistics (Mann-Whitney U, KruskalWallis, χ2, and Fisher exact tests) were used. p values < .05 were considered significant.
RESULTS A total of 93 questionnaires were collected from patients with itch-scratch; 232, patients with vulvodynia; and 104, patients who presented for annual gynecologic examination. Age, race, marital status, proportion having had at least 1 vaginal delivery, and history of elective abortion were not significantly different in the 3 groups (see Table 1). By contrast, the highest level of education completed, gravidity, and parity were significantly different when comparing the 3 study groups. There was a trend toward different parity among the 3 groups, but this did not reach statistical significance at the .05 level with our sample sizes. Bivariate analysis confirmed that patients from the annual examination group were more likely to have obtained college or postgraduate degrees than patients from either the itch-scratch or vulvodynia groups, whereas the itch-scratch and vulvodynia groups had similar distributions of educational attainment (see Table 1). The highest gravidity was found among patients in the itch-scratch group, followed by patients in the vulvodynia group, with the lowest rates in patients in the annual examination group. Patients in the itch-scratch group similarly had higher parity than either of the other 2 groups, but there was no significant difference in parity when comparing the vulvodynia and annual examination groups. There was a similarly higher proportion of patients in the itch-scratch group than patients in the vulvodynia group who had
Journal of Lower Genital Tract Disease • Volume 19, Number 3, July 2015
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Journal of Lower Genital Tract Disease • Volume 19, Number 3, July 2015
Sexual Abuse and Vulvar Disease
TABLE 1. Demographics and Obstetric History
Age (y)
Itch-scratch
Vulvodynia
Annual gynecologic examination
p
41.5 (31.0–51.0) [16–78]
40.0 (30.3–51.0) [19–90]
43.0 (29.0–53.0) [20–75]
.92
0 2.2 (2/92) 7.6 (7/92) 88.0 (81/92) 6.5 (6/92) 0
0.4 (1/230) 3.5 (8/230) 5.7 (13/230) 86.5 (199/230) 0.9 (2/230) 3.0 (7/230)
1.0 (1/103) 3.9 (4/103) 5.8 (6/103) 85.4(88/103) 1.0 (1/103) 2.9 (3/103)
19.4 (18/93) 65.6 (61/93) 1.1 (1/93) 12.9 (12/93) 1.1 (1/93)
24.8 (57/230) 67.8 (156/230) 0.4 (1/230) 5.7 (13/230) 1.3 (3/230)
33.7 (35/104) 53.8 (56/104) 2.9 (3/104) 8.7 (9/104) 1.0 (1/104)
3.3 (3/92) 9.8 (9/92) 28.3 (26/92) 8.7 (8/92) 25.0 (23/92) 25.0 (23/92) 2 (1–3) [0–9] 2 (1–2) [0–8] 82.4 (61/74) 18.9 (14/74)
1.7 (4/232) 10.3 (24/232) 26.3 (61/232) 12.9 (30/232) 27.2 (63/232) 21.6 (50/232) 2 (0–3) [0–8] 1 (0–2) [0–7] 68.8 (106/154) 14.9 (23/154)
1.9 (2/104) 1.9 (2/104) 16.3 (17/104) 7.7 (8) 32.7 (34/104) 39.4 (41/104) 1 (0–2) [0–4] 1 (0–2) [0–3] 78.9 (45/57) 8.8 (5/57)
Race American Indian / Alaskan Native Asian Black/African American White Middle Eastern More than 1 race Marital status Single Married Separated Divorced Widowed Education Grade school Completed high school Some college Associate degree Bachelor’s degree Postgraduate degree Gravidity Parity Ever had vaginal delivery Reports ever having had an abortion
.93
.09
.008
V
ulvar pruritus and vulvodynia are 2 of the most common vulvar diseases encountered by vulvar specialists.1–8 The etiologic factors for the development of these 2 conditions are enigmatic. Many hypotheses were suggested throughout years of research, including atopy and eczema for chronic pruritus,9 and infection, inflammation, and chronic neuropathic pain for vulvodynia.7,10–17 The role of psychologic factors and stress in the etiology of both diseases was also discussed in previous articles.18–20 There have been several studies suggesting that patients with vulvodynia are not more likely to have suffered previous sexual or physical abuse.21–23 However, no studies, to our knowledge, have looked for a possible correlation between vulvar pruritus and a past trauma of sexual or physical abuse. In this article, we compared gynecologic and general health background, and a history of physical and sexual abuse, collected from questionnaires from patients with chronic vulvar pruritus and with vulvodynia and healthy patients
1
Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel; and 2Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI Correspondence to: Bina Cohen Sacher, MD, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel. E-mail: [email protected] This research was supported by Michigan BIRCWH Career Development Program grant K12 HD001438. M.B.B. received investigator support through the National Institute of Child Health and Human Development BIRCWH Career Development Award K12 HD001438. The authors thank the University of Michigan CTSA for the use of the REDCap electronic database and for the grant support (No. UL1RR024986). The authors have declared they have no conflicts of interest. © 2015, American Society for Colposcopy and Cervical Pathology
248
presenting for routine annual gynecologic examinations. We aim to test the hypothesis that women with chronic vulvar pruritus report similar rates of past sexual and/or physical abuse as controls with vulvodynia or women presenting for routine annual examinations.
MATERIALS AND METHODS Every new patient presenting for evaluation and treatment in the University of Michigan Center for Vulvar Diseases in Ann Arbor, MI, completes a questionnaire that is de-identified. These questionnaires contain closed questions regarding their symptoms, their general medical and gynecologic history, the McGill Pain Questionnaire, and questions regarding sexuality and sexual relations. When examined at the clinic, diagnosis is made by the health care provider based on the symptoms, course of disease, and findings in the physical examination. Approval was obtained from the University of Michigan Institutional Review Board. All available completed questionnaires from patients with itchscratch (I-S) and vulvodynia (V) were included in this study. A convenience sample of 2,012 women 18 years and older, presenting for annual gynecologic examinations at the University of Michigan Obstetrics and Gynecology Clinic between March and August, were recruited as healthy controls. These women completed a subset of questions (relevant for this study) from the Center for Vulvar Diseases New Patient Questionnaire. Responses from the questionnaires were entered into electronic databases using REDCap and exported for analysis in SPSS Version 19.0 (SPSS, Inc., IBM Corporation, Armonk, NY). Appropriate standard descriptive statistics (Mann-Whitney U, KruskalWallis, χ2, and Fisher exact tests) were used. p values < .05 were considered significant.
RESULTS A total of 93 questionnaires were collected from patients with itch-scratch; 232, patients with vulvodynia; and 104, patients who presented for annual gynecologic examination. Age, race, marital status, proportion having had at least 1 vaginal delivery, and history of elective abortion were not significantly different in the 3 groups (see Table 1). By contrast, the highest level of education completed, gravidity, and parity were significantly different when comparing the 3 study groups. There was a trend toward different parity among the 3 groups, but this did not reach statistical significance at the .05 level with our sample sizes. Bivariate analysis confirmed that patients from the annual examination group were more likely to have obtained college or postgraduate degrees than patients from either the itch-scratch or vulvodynia groups, whereas the itch-scratch and vulvodynia groups had similar distributions of educational attainment (see Table 1). The highest gravidity was found among patients in the itch-scratch group, followed by patients in the vulvodynia group, with the lowest rates in patients in the annual examination group. Patients in the itch-scratch group similarly had higher parity than either of the other 2 groups, but there was no significant difference in parity when comparing the vulvodynia and annual examination groups. There was a similarly higher proportion of patients in the itch-scratch group than patients in the vulvodynia group who had
Journal of Lower Genital Tract Disease • Volume 19, Number 3, July 2015
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Journal of Lower Genital Tract Disease • Volume 19, Number 3, July 2015
Sexual Abuse and Vulvar Disease
TABLE 1. Demographics and Obstetric History
Age (y)
Itch-scratch
Vulvodynia
Annual gynecologic examination
p
41.5 (31.0–51.0) [16–78]
40.0 (30.3–51.0) [19–90]
43.0 (29.0–53.0) [20–75]
.92
0 2.2 (2/92) 7.6 (7/92) 88.0 (81/92) 6.5 (6/92) 0
0.4 (1/230) 3.5 (8/230) 5.7 (13/230) 86.5 (199/230) 0.9 (2/230) 3.0 (7/230)
1.0 (1/103) 3.9 (4/103) 5.8 (6/103) 85.4(88/103) 1.0 (1/103) 2.9 (3/103)
19.4 (18/93) 65.6 (61/93) 1.1 (1/93) 12.9 (12/93) 1.1 (1/93)
24.8 (57/230) 67.8 (156/230) 0.4 (1/230) 5.7 (13/230) 1.3 (3/230)
33.7 (35/104) 53.8 (56/104) 2.9 (3/104) 8.7 (9/104) 1.0 (1/104)
3.3 (3/92) 9.8 (9/92) 28.3 (26/92) 8.7 (8/92) 25.0 (23/92) 25.0 (23/92) 2 (1–3) [0–9] 2 (1–2) [0–8] 82.4 (61/74) 18.9 (14/74)
1.7 (4/232) 10.3 (24/232) 26.3 (61/232) 12.9 (30/232) 27.2 (63/232) 21.6 (50/232) 2 (0–3) [0–8] 1 (0–2) [0–7] 68.8 (106/154) 14.9 (23/154)
1.9 (2/104) 1.9 (2/104) 16.3 (17/104) 7.7 (8) 32.7 (34/104) 39.4 (41/104) 1 (0–2) [0–4] 1 (0–2) [0–3] 78.9 (45/57) 8.8 (5/57)
Race American Indian / Alaskan Native Asian Black/African American White Middle Eastern More than 1 race Marital status Single Married Separated Divorced Widowed Education Grade school Completed high school Some college Associate degree Bachelor’s degree Postgraduate degree Gravidity Parity Ever had vaginal delivery Reports ever having had an abortion
.93
.09
.008
