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Oral contraceptive use was associated with a 7-fold increase in the risk of vulvar vestibulitis
GYNECOLOGY
Oral contraceptive use was associated with a 7-fold increase in the risk of vulvar vestibulitis Bouchard C, Brisson J, Fortier M, Morin C, Blanchette C.Use of oral contraceptive pills and vulvar vestibulitis: a case^control study. Am J Epidemiol 2002; 156: 254 ^261.
OBJECTIVE To determine if there is an association between the use of oral contraceptives (OCs) and vulvar vestibulitis in young women. DESIGN Case^control study. SETTING University hospital in Canada. SUBJECTS Cases were138 women, aged16^35 (mean 22) years, with newly diagnosed vulvar vestibulitis and secondary super¢cial dyspareunia of 3^24 (mean 12) months duration. Controls were 309 sexually active women without vestibular pain during intercourse, recruited from nongynecologic clinics in the hospital and matched to cases by age. Pregnant women were excluded. METHODS Cases and controls were interviewed in person by a nurse to obtain information about reproductive and gynecologic history, and details of OC use. Only OC use up to the onset of symptoms was considered for the cases, and up to 12 months prior to the interview for controls. OCs were classi¢ed in two ways: as low or high estrogenic, androgenic, and progestogenic potency, and as ¢rst, second, or third generation. MAIN OUTCOME MEASURES Relative risk (RR, 95% CI) of developing vulvar vestibulitis in OC users, compared to never-users, adjusted for other risk factors, such as age, marital status, education, body mass
24
Evidence-based Obstetrics and Gynecology (2003) 5, 24 ^25 doi:10.1016/S1361-259X(03)00027- 8
index, age at menarche and ¢rst intercourse, and number of lifetime sexual partners. MAIN RESULTS For both cases and controls, 72% of women were single, mean age at menarche was just under 13 years and mean age at ¢rst intercourse was 16 years. Mean number of sexual partners was 4.7 for cases and 5.8 for controls. Ninetysix percent of cases and 83% of controls had used OC at some time, and 80 and 61%, respectively, were current users. The RR of vulvar vestibulitis was 6.6 (2.5^17) with ever-use of OC, 7.1 (2.7^19) with current use, and 4.3 (1.4^13) with past use. The risk of vulvar vestibulitis was signi¢cantly increased even with o1 year of OC use (RR 6), but was somewhat higher (RRs between 7 and 8) with 42 years of use. If the age at ¢rst OC use was o16 years, the RR for vulvar vestibulitis was 9.3 (3.2^27), compared to never-users. This ¢gure decreased to 6.2 (2.3^17) with ¢rst use at 16^17 years, and to 5.4 (1.9^15) with ¢rst use at 18 years or older. All types of OC were associated with a signi¢cantly increased risk of vulvar vestibulitis, but the risks were higher for OCs of high progestogenic or androgenic potency, or low estrogenic potency. The RR with second generation OC was slightly higher than that with third generation. CONCLUSION Oral contraceptive use was associated with a 7-fold increase in the risk of developing vulvar vestibulitis. The risk was higher with current, long-term, or early use and with use of OC of high progestogenic and androgenic potency and low estrogenic potency.
1361-259X/03/$ - see front matter & 2003 Elsevier Science Ltd. Allrights reserved.
Commentary So far, there has been diff|culty in def|ning factors that predispose to or influence the susceptibility to vulvar vestibulitis (VV); furthermore, its aetiology is unclear. The f|ndings of this case ^ control study suggest a strong association between oral contraceptive (OC) use and VV. The methodological approach chosen was appropriate, given that VV is uncommon, and it also allows for the evaluation of multiple common aetiologic factors.The choice of appropriate controls is central to the validity of case ^ control studies. The use of controls from non-gynaecological clinics theoretically meets this requirement, but there is a possibility that the controls had conditions that precluded use of the OC. Also, it is not clear if the nurse extracting the information was blinded to the subject’s status as case or control. Furthermore, recall bias is often a problem in studies of this design, particularly as cases are likely to have better recall of OC use than controls. Nonetheless, hospital controls would probably remember OC use better than general population controls. The cases had an examination, as required, for making the diagnosis of VV using Friedrich’s criteria; however, the controls did not. Even though the reliability of the diagnosis of VV can be problematic,1 the omission of examination of controls is understandable, as this invasive procedure may have made recruitment more difficult. This study, unlike two previous ones (including one by the authors of the present study), explored the putative association between oral contraceptive use and VV and attempted to control for other biologically plausible confounding factors; however, parity and fertility should have been taken into account, as these factors may affect OC use. While other studies have suggested that psychosexual factors,2 previous local vulvo-vaginal infections, and systemic differences in pain thresholds are more common in women with VV,3 these findings could reflect multi-
& 2003 Elsevier Science Ltd. All rights reserved.
factorial elements to the pathogenesis and aetiology of this condition. The present study was limited in its ability to attribute a cause to the women’s VV and could only explore associations using relative risks.The observation of high androgen and high progesterone content pills being associated with more disease is difficult to explain, but may imply an adverse effect of the hormonal milieu on vestibulitis in women. Conversely, one cannot discount the possibility that, for women with VV, psychosocial reasons influence why they use the pill, for how long, and at what age. This notion does not diminish the observation in the present study of the unfavourable effect in association with OC pill usage and highlights the need to raise awareness of VV in OC users. Until a causal effect is demonstrated, women should not be discouraged from using OCs, but should be made aware of VV being associated with its use. Further study on this topic is warranted; until more data show direct evidence that the OC or similar hormonal preparations alter the onset or progression of VV, the issue will remain controversial. Valentine A. Akande MBBS PhD and Roshni R. Patel MBBS, MSc University of Bristol, Bristol, UK Literature cited 1. Bergeron S, Binik YM, Khalif!e S et al. Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria.Obstet Gynecol 2001; 98: 45^51. 2. Danielsson I, Sjoberg I, Wikman M. Vulvar vestibulitis: medical, psychological and psychosocial aspects, a case control study. Acta Obstet Gynecol Scand 2000; 79: 872^ 878. 3. Granot M, Fiedman M,Yarnitsky D et al. Enhancement of the perception of systemic pain in women with vulvar vestibulitis. Br J Obstet Gynecol 2002; 109: 863^ 866.
Evidence-based Obstetrics and Gynecology (2003) 5, 24 ^25
25
Oral contraceptive use was associated with a 7-fold increase in the risk of vulvar vestibulitis Bouchard C, Brisson J, Fortier M, Morin C, Blanchette C.Use of oral contraceptive pills and vulvar vestibulitis: a case^control study. Am J Epidemiol 2002; 156: 254 ^261.
OBJECTIVE To determine if there is an association between the use of oral contraceptives (OCs) and vulvar vestibulitis in young women. DESIGN Case^control study. SETTING University hospital in Canada. SUBJECTS Cases were138 women, aged16^35 (mean 22) years, with newly diagnosed vulvar vestibulitis and secondary super¢cial dyspareunia of 3^24 (mean 12) months duration. Controls were 309 sexually active women without vestibular pain during intercourse, recruited from nongynecologic clinics in the hospital and matched to cases by age. Pregnant women were excluded. METHODS Cases and controls were interviewed in person by a nurse to obtain information about reproductive and gynecologic history, and details of OC use. Only OC use up to the onset of symptoms was considered for the cases, and up to 12 months prior to the interview for controls. OCs were classi¢ed in two ways: as low or high estrogenic, androgenic, and progestogenic potency, and as ¢rst, second, or third generation. MAIN OUTCOME MEASURES Relative risk (RR, 95% CI) of developing vulvar vestibulitis in OC users, compared to never-users, adjusted for other risk factors, such as age, marital status, education, body mass
24
Evidence-based Obstetrics and Gynecology (2003) 5, 24 ^25 doi:10.1016/S1361-259X(03)00027- 8
index, age at menarche and ¢rst intercourse, and number of lifetime sexual partners. MAIN RESULTS For both cases and controls, 72% of women were single, mean age at menarche was just under 13 years and mean age at ¢rst intercourse was 16 years. Mean number of sexual partners was 4.7 for cases and 5.8 for controls. Ninetysix percent of cases and 83% of controls had used OC at some time, and 80 and 61%, respectively, were current users. The RR of vulvar vestibulitis was 6.6 (2.5^17) with ever-use of OC, 7.1 (2.7^19) with current use, and 4.3 (1.4^13) with past use. The risk of vulvar vestibulitis was signi¢cantly increased even with o1 year of OC use (RR 6), but was somewhat higher (RRs between 7 and 8) with 42 years of use. If the age at ¢rst OC use was o16 years, the RR for vulvar vestibulitis was 9.3 (3.2^27), compared to never-users. This ¢gure decreased to 6.2 (2.3^17) with ¢rst use at 16^17 years, and to 5.4 (1.9^15) with ¢rst use at 18 years or older. All types of OC were associated with a signi¢cantly increased risk of vulvar vestibulitis, but the risks were higher for OCs of high progestogenic or androgenic potency, or low estrogenic potency. The RR with second generation OC was slightly higher than that with third generation. CONCLUSION Oral contraceptive use was associated with a 7-fold increase in the risk of developing vulvar vestibulitis. The risk was higher with current, long-term, or early use and with use of OC of high progestogenic and androgenic potency and low estrogenic potency.
1361-259X/03/$ - see front matter & 2003 Elsevier Science Ltd. Allrights reserved.
Commentary So far, there has been diff|culty in def|ning factors that predispose to or influence the susceptibility to vulvar vestibulitis (VV); furthermore, its aetiology is unclear. The f|ndings of this case ^ control study suggest a strong association between oral contraceptive (OC) use and VV. The methodological approach chosen was appropriate, given that VV is uncommon, and it also allows for the evaluation of multiple common aetiologic factors.The choice of appropriate controls is central to the validity of case ^ control studies. The use of controls from non-gynaecological clinics theoretically meets this requirement, but there is a possibility that the controls had conditions that precluded use of the OC. Also, it is not clear if the nurse extracting the information was blinded to the subject’s status as case or control. Furthermore, recall bias is often a problem in studies of this design, particularly as cases are likely to have better recall of OC use than controls. Nonetheless, hospital controls would probably remember OC use better than general population controls. The cases had an examination, as required, for making the diagnosis of VV using Friedrich’s criteria; however, the controls did not. Even though the reliability of the diagnosis of VV can be problematic,1 the omission of examination of controls is understandable, as this invasive procedure may have made recruitment more difficult. This study, unlike two previous ones (including one by the authors of the present study), explored the putative association between oral contraceptive use and VV and attempted to control for other biologically plausible confounding factors; however, parity and fertility should have been taken into account, as these factors may affect OC use. While other studies have suggested that psychosexual factors,2 previous local vulvo-vaginal infections, and systemic differences in pain thresholds are more common in women with VV,3 these findings could reflect multi-
& 2003 Elsevier Science Ltd. All rights reserved.
factorial elements to the pathogenesis and aetiology of this condition. The present study was limited in its ability to attribute a cause to the women’s VV and could only explore associations using relative risks.The observation of high androgen and high progesterone content pills being associated with more disease is difficult to explain, but may imply an adverse effect of the hormonal milieu on vestibulitis in women. Conversely, one cannot discount the possibility that, for women with VV, psychosocial reasons influence why they use the pill, for how long, and at what age. This notion does not diminish the observation in the present study of the unfavourable effect in association with OC pill usage and highlights the need to raise awareness of VV in OC users. Until a causal effect is demonstrated, women should not be discouraged from using OCs, but should be made aware of VV being associated with its use. Further study on this topic is warranted; until more data show direct evidence that the OC or similar hormonal preparations alter the onset or progression of VV, the issue will remain controversial. Valentine A. Akande MBBS PhD and Roshni R. Patel MBBS, MSc University of Bristol, Bristol, UK Literature cited 1. Bergeron S, Binik YM, Khalif!e S et al. Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria.Obstet Gynecol 2001; 98: 45^51. 2. Danielsson I, Sjoberg I, Wikman M. Vulvar vestibulitis: medical, psychological and psychosocial aspects, a case control study. Acta Obstet Gynecol Scand 2000; 79: 872^ 878. 3. Granot M, Fiedman M,Yarnitsky D et al. Enhancement of the perception of systemic pain in women with vulvar vestibulitis. Br J Obstet Gynecol 2002; 109: 863^ 866.
Evidence-based Obstetrics and Gynecology (2003) 5, 24 ^25
25