The Australian and New Zealand Vulvovaginal Society

Do you work with patients with a v***a or va**na? Are you interested in the va**nal microbiome or v***al pain syndromes? Do you need more information about management of Lichen sclerosus or Lichen planus? Come to the ANZVS V***a education day in Sydney Saturday 11 November 2023. All the superstars will be there: Jill Krapf (online), Yvette Ius, Tania Day, Charlotte Elder!

Australia & New Zealand Vulvova**nal Society Cancellation Policy: Cancellations received by 7/9/23 will receive a full refund less a $100 cancellation fee.  There will be no refunds for cancellations received after 7/9/23.   

Highlights from the

Paivi Tommola reviewed the interpretation of wet mounts with an array of helpful analogies.

Bacterial vaginosis = grains of rice = fat rods
with
Clue cells = furry and fluffy

Aerobic vaginitis / DIV = salt & pepper = mostly cocci with some rods
with
Parabasal cells = sunny side up eggs

Candidiasis has
Blastospheres = eggs or mini-snowmen
&
Hyphae = branches from trees or a toilet brush

Indulge your visual extrapolation side and explore adding microscopy to clinical your tool box!





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Highlights of
Dr Jasmine Abdulcadir provided a trenchant analysis of the social construct of virginity and a thoughtful rebuke of medical provision of "h***noplasty."

She began with a case of h***noplasty complications that required emergency surgery to restore v***al function. This set the stage for discussion of 1) the set of assumptions surrounding the decision of some doctors to do this procedure and 2) how those actions reinforce harmful ideas about virginity and the worth of women and girls in society.

It is a privilege to listen to an expert speak to the ethical considerations that must accompany the requests we might receive from patients and families.

Further insights can be found in Dr Abdulcadir's published work.
https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15887
https://academic.oup.com/asj/article/42/2/NP137/6415693

https://www.nuoveradici.world/articoli-in-evidenza/jasmine-abdulcadir-the-gynecologist-fighting-female-ge***al-mutilation-who-was-awarded-a-knighthood-from-the-italian-republic/



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Highlights from

Prof Hans Verstraelen gave an excellent and thought-provoking talk about the 'normal' microbiome.

Normal is a problem word across many areas of medicine. It makes more sense to think about whether or not the microbiome is associated with symptoms or poorer health outcomes.

The microbiome is complicated - it includes the microorganisms themselves plus the environment within which they exist. Microbiota influence their surroundings and likewise are affected by their environment.

A key clinical message is that culture results tell you almost nothing about the state of wellness of the v*gina. Do not treat isolated culture or PCR findings unless there the clinical picture suggests a pathological process. A culture result of Gardnerella is NOT diagnostic of bacterial vaginosis!

If you want to read more about this topic, there is an open access article on the topic published in the JLGTD.
https://biblio.ugent.be/publication/8739241

The ISSVD has also published a resource about vaginitis diagnosis and treatment that includes an excellent chapter about 'normal'.
https://www.issvd.org/resources/recommendations-for-the-diagnosis-and-treatment-of-vaginitis

Highlights from

An Irish dermatologist presented an abstract about AI and

Turns out that ChatGPT’s response to a prompt about LS management focuses more on risks of topical corticosteroids rather than benefits of appropriate treatment.

Audience members had not yet been aware of patients using the app in preparation for consultations…but acknowledged this is probably happening and it would be useful to know the biases being reflected from data sources into the AI scripts.

AI has not yet figured out how to generate an image of a v***a affected by LS. Seems like this is a good thing?

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Highlights from the conference in Helsinki

Dr Moyal-Barracco kicked off the conference with her excellent presentation on normal anatomy.

Non-recognition of normal variation results in the necessary anxiety for patients, potential iatrogenic harm, and poor utilisation of healthcare resources.

Common normal and benign findings include:
- h***nal tag (aka remnant, caruncle) = a prominent area of the h***n, often formed after stretching and tearing of the h***n during va**nal birth
- physiologic redness = flat, symmetric, poorly defined borders, often in people with pale skin tones
- vestibular papillomatosis = soft skin-coloured projections, usually on inner l***a minora, each with a separate base
- angiokeratomas = ectatic blood vessels in superficial dermis
- epidermal cyst = keratinising squamous epithelium trapped within the dermis produces keratin, which fills the cyst

To learn normal, clinicians can engage their powers of observation during every ge***al/speculum exam.

Some open access resources on this topic include:
A review of benign lumps and bumps:
https://www.sciencedirect.com/science/article/pii/S2352647521000605

A critical analysis of medical education in ge***al anatomy and how this contributes to a "knowledge shortfall" among health practitioners:
https://anatomypubs.onlinelibrary.wiley.com/doi/full/10.1002/ase.2173



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Highlights from the in Helsinki

A French dermatologist presented 2 cases of localised v***al argyria due to many years of topical silver sulfadiazine (flamazine) on the vestibule.

Examination in both cases showed heterogenous pigmented patches worrisome for melanoma. Biopsy provided the diagnosis.

At other body sites, cosmetic LASER can restore a more normal colour, but at this location the management was to stop the exposure to silver.

Take home message - do not chronically expose the skin to silver! There are lots of options for soothing emollients that will not produce altered pigmentation.

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Many people have a difficult relationship with their v***a. Valentine's day is a great opportunity to reflect on the feelings we have about our bodies, and try to shift those to love and appreciation, rather than judgment, disappointment, or shame.
v***a.gallery does hugely important work in this area. Hilde Atalanta, the artist and visionary behind it all, offers us a fantastic IG page, a website, a book, educational materials, and even a collaboration with Netflix. This all serves to educate people and inspire them to accept and enjoy their v***as rather than perceive flaws.

No two people look alike, and neither do two v***as. Moreover, the v***a does many essential jobs. Attempts to change the appearance of the v***a may negatively impact on function. Each of us in our interactions with patients can reassure about normal anatomy and support body positivity.

Many people have a difficult relationship with their v***a. Valentine's day is a great opportunity to reflect on the feelings we have about our bodies, and try to shift those to love and appreciation, rather than judgment, disappointment, or shame. @the.v***a.gallery does hugely important work in this area. Hilde Atalanta, the artist and visionary behind it all, offers us a fantastic IG page, a website, a book, educational materials, and even a collaboration with Netflix. This all serves to educate people and inspire them to accept and enjoy their v***as rather than perceive flaws. No two people look alike, and neither do two v***as. Moreover, the v***a does many essential jobs. Attempts to change the appearance of the v***a may negatively impact on function. Each of us in our interactions with patients can reassure about normal anatomy and support body positivity. #v***adiversity #v***arspecialist #thev***agallery #v***aranatomy #clitoralanatomy #v***apositive #s*xualhealtheducation #gynecologist #gynaecologists #dermatologist #s*xualhealthphysician #pelvicfloorphysio #womenshealthnursepractitioner

A cross-sectional study of contact allergens in feminine hygiene wipes

The authors searched 5 major US-based retailers and selected 28 different brands and 34 unique hygienic wipe products advertised for sweat, s*x, menstrual cycle, and/or home/public bathroom.

It comes as no surprise that "every product analyzed contained at least one possible allergen, with a mean of 3.53 allergens per product."

Highlighting the mismatch between marketing claims and reality, "9 products were advertised as “sensitive,” “natural,” “fragrance free,” “soothing,” or “organic.” Products with these claims did not have a statistically significant difference in total number of allergens compared to products that did not make these claims (mean of 3.11 vs 3.68, P = 0.31)"

In short - this is a product that doesn't need to exist and has potential for harm. In contrast, cleansing with water is safe, effective, and inexpensive.

https://journals.lww.com/ijwd/Fulltext/2022/12000/A_cross_sectional_study_of_contact_allergens_in.6.aspx

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There is very little written about vulvova**nal health in transmen. This survey study reports than 60% of respondents have s*xual pain, with no significant difference between those on testosterone and those not on it. There was no clinical review so we have no idea what the causes of pain were in the study population. As in cisgender people, pain is likely to be multifactorial and often involves the v***a and pelvic floor (much more than 10% of cases!). Hopefully centres that specialise in multidisciplinary care of trans people can provide more data about v***al pain and skin conditions in this group to shed light on tailored management approaches. https://www.liebertpub.com/doi/10.1089/lgbt.2020.0357?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed #v***arspecialist #transcare #v***arpain #v***arpainawareness #gynaecologist #gynecologist #s*xualhealthphysician #womenshealthnursepractitioner

Case reports often provide useful clinical pearls for every day practice and make us wonder "is there something I might be missing?".

This one contains a couple of photos of advanced malignancies, so approach with caution.

A couple of key messages:
**V***ar cancer associated with hidradenitis suppurativa (HS) can be HPV-related or HPV-independent. HS combines chronic inflammation with scar, as does lichen sclerosus.

**Cancer can hide out deep in sinus tracts so superficial biopsies can miss it. If there is an unusual, nodular, bleeding, or profusely discharging lesion, consider excisional biopsy.

**In a literature review across all genders, mean age at cancer diagnosis was 52 and max was 78. As always, if a postmenopausal person presents with an exacerbation of an old problem, think about neoplasia.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8784320/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949826/

Case reports often provide useful clinical pearls for every day practice and make us wonder "is there something I might be missing?". This one contains a couple of photos of advanced malignancies, so approach with caution. A couple of key messages: **V***ar cancer associated with hidradenitis suppurativa (HS) can be HPV-related or HPV-independent. HS combines chronic inflammation with scar, as does lichen sclerosus. **Cancer can hide out deep in sinus tracts so superficial biopsies can miss it. If there is an unusual, nodular, bleeding, or profusely discharging lesion, consider excisional biopsy. **In a literature review across all genders, mean age at cancer diagnosis was 52 and max was 78. As always, if a postmenopausal person presents with an exacerbation of an old problem, think about neoplasia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8784320/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949826/ #v***arcancerawareness #hidradenitissuppurativa #humanpapillomavirus #gynecology #gynaecology #gynecologiconcology #gynaecologiconcology #dermatologytips

During January 2023 we'll recap some of the publications and projects than caught our attention in 2022. First off, an interesting study on 'what not to do' when communicating with people about vulvova**nal disorders: https://journals.lww.com/jlgtd/Abstract/2022/01000/_Worse_Than_Disappointing___Prediagnostic_Health.11.aspx It is hard for individuals to influence our complicated health systems and maldistribution of well-trained health professionals. But we can easily avoid some of the common "provider-based challenges" called out in this article: - Dismissing symptoms as age-related, maybe an STI, 'in your head', thrush, or 'just irritation' - Blaming the patient by saying the problem is due to their weight, their s*xual practices, not washing enough, having too much or not enough p***c hair, or their anxiety - Telling the patient they can't have a certain diagnosis because they don't fit the textbook description (LS in young women, HSIL in older women) - Saying everything is fine because all the swabs are negative - Repeating general v***ar care advice (white cotton un**es!!) without making a diagnosis or providing specific treatment - Just not knowing enough about the conditions to provide helpful advice. As health professionals, our words and actions are powerful...and this is especially true when communicating about the ge***al region. If you see patients with vulvova**nal disorders and wish you felt a bit more comfortable with diagnosis & management of these conditions, the ANZVS is here for you! #v***arspecialist #v***arskinconditions #v***arpain #lichensclerosus #healthcarebarriers #diagnosticdelay

Yasmin Tan, Sydney-based gynaecologist, reviewed the medical management of vulvova**nal pain syndromes with a focus on dealing with nociplastic contributors.

She underscored the importance of explaining pain, reviewing options and their respective benefits and drawbacks, and providing hope with a way forward.

Familiarising yourself with the tricyclics, gabapentinoids, and SNRIs is an important step towards managing v***al pain syndromes, which are so often comorbid with other pain conditions.


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After a post-conference rest, ANZVS is back on the socials.

There is a bit more to say about our amazing final day speakers and sessions.

Susan Evans blew us all away with a summation of her PhD work on a unifying theory for immune-mediated (via Toll-like receptors) mechanisms of dysmenorrhea, chronic pelvic pain, and endometriosis.

So many memorable messages…
- the gender pain discrepancy starts at menarche and 20% of girls are predisposed to dysmenorrhea and pelvic pain
- ‘feel bad’ symptoms and comorbid pain syndromes occur whether endometriosis is present or absent
- pain communication between the pelvic viscera and the central nervous system is a two-way street, eg orthodromic and antidromic
- increased cytokines and circulating immune cells activate spinal glia that develop and maintain ‘feel bad’ symptoms like fatigue, poor sleep, low mood, anxiety, and nausea

This is a big, fascinating, and complex topic and worth independent reading.

Check out resources and links from Susan’s webpage and the




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We were delighted to hear from Prof Sophie Bergeron in Montreal. She is internationally renowned for groundbreaking work in the epidemiology and s*xologic treatment of s*xual and v***al pain.

Cognitive behavioural therapy works and may be undertaken with individuals, couples, and groups. It is about influencing pain-related thoughts, feelings, and behaviours to break the cycle of fear-anxiety-avoidance-decreased function.

Feelings of empowerment, hope, and self-efficacy are themselves therapeutic.

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Patricia Neumann provided a masterclass in pain nomenclature, mechanisms, trauma-informed examination strategies, pelvic floor musculoskeletal & neuroanatomy, and treatment approaches that physios may offer.

Key messages were around comorbid pain conditions with central mechanisms and how exercise, active relaxation, mind-body activities, gradual desensitisation to touch and pressure, breathing, improved voiding techniques, and so many other approaches can dial back central pain mechanisms.

The final slide is a comprehensive review of how to examine the pelvic floor.



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Claudia Marchitelli encourages all of us to address s*xuality with our patients. We all know the barriers - especially time - but it is so important for many people’s quality of life.

She reviewed the PLISSIT model to structure our consultation:
P=permission to talk about it without fear of judgment or dismissal

LI=limited information means to provide general education about gender differences in s*xual arousal and response

SS=specific suggestions tailored to the patient’s situation - this might include use of toys, silicone based l**e, erotica (SBS get a room section might be a gateway resource), increasing time for play and touch and decreasing pe*******on time, expressing needs and desires to partner

IT=intensive treatment is required for some people and might involve a s*xologist, pelvic floor physio, and/or psychologist with an interest in s*xual wellness

Thank you Claudia for your advocacy and cheerleading around s*xual health and pleasure for people with v***al conditions!! 😇

ok

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Our inaugural Pathology Workshop was a great success 🥳😁🥂

Karen Tahlia hosted the session and gave an elegant talk on precursor lesions.

We were delighted to have specialists and trainees present a variety of challenging cases like v***al Paget’s, mixed va**nal tumours, and the differential diagnosis of vulvova**nal cysts.

We’ll use participant feedback to inform future events - let us know what you would find most helpful in a Path Workshop - topics, speakers, format, audience make-up, and time for discussion.

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Prof Sonia Grover delivered 2 thought-provoking talks about conge***al&structural v***al conditions and v***al dysethesia in children.

Many teaching points so just a few summarised here:

Consider your language carefully. Words like ambiguous and abnormal can be misleading or harmful. Variation or difference or atypical are preferred descriptors.

If there are atypical ge***alia at birth, plan to do day 5 electrolytes and 17OHP. Don’t assign a gender to the baby and ensure staff do the same until investigations have been completed.

Prepubertal l***al fusion does NOT need treatment - no oestrogen, no separation. Prof Grover has seen 2 cases in 30 years of voiding obstruction from l***al fusion. This is the sole indication for l***al separation under adequate analgesia.

Rhabdomyosarcoma can present as v***al nodules or red induration. Get imaging and basic bloods and make a return visit in 2-3 weeks. If the lesion has grown, it unfortunately is worrisome for this diagnosis.


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We enjoyed 2 engaging talks by Dra Ariadne Caussade this morning.

She emphasised that childrens’ symptoms often involve bladder, bowel, and sleep disturbance.

Key tips:
Don’t be afraid of using steroids for lichen sclerosus. Using too little is both common and harmful.

Prepubertal children do not benefit from oestrogen for their skin problems.

Prepubertal children almost never have candidiasis. Don’t empirically give antifungals to children - they cause harm and do not help.
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Dermatology luminaries Tanja Bohl and Gayle Fischer gave us a lot to think about when we see erosions or ulcers. It starts with using the right word for what we see. A big topic so below are a few highlights.

Ulcers
The most common diagnosis is aphthosis - this can be simple or complex, but has a characteristic appearance and mostly occurs in children and young people.

Ulcers that grow rapidly and may be multiple might be pyoderma gangrenosum - associated with autoimmune diseases, haem malignancies, and rituximab.

Erosions
Think about fixed drug eruption if there is redness & erosions. Ask about over the counter analgesics and antibiotics.

Herpes zoster is always unilateral.

When recurrent erosions are on mouth and v***a at the same time (and it is not lichen planus) think about recurrent erythema multiforme, which is often triggered by HSV and gets better with valacyclovir.

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Dr Janet Towns carried us through 15000 years (!!!) of syphilis history and then discussed some important dogma-bashing points.

Chancres can be both multiple and painful.

In treponema pallidum PCR positive patients, 20% are serology negative on initial bloods.

T pallidum lives in saliva and syphilis can be transmitted by kissing.

Syphilis in the mouth can be red, pink, or white, flat or raised or ulcerated. As everywhere else, it is the great pretender.

If you see a lesion anywhere in a potentially susceptible person, swab it PCR for T Pallidum is the optimal approach.

Condyloma lata are a mimic for ge***al warts. If someone has a lot of pain with cryo, think about syphilis.

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Joanne Peel provided an excellent primer on taking a respectful and comprehensive s*xual history. Language is key. Asking people about their gender identity and preferred pronouns demonstrates respect and builds rapport.

Helpful non-judgmental questions include:
What gender are your partners?
What age are your partners (especially for young people)?
About how many partners have you had in the past 3 and 12 months?
What types of s*x do you have and do you use condoms during these?
How do you meet partners?
Do you exchange s*x for other things/goods?
Do you feel able to negotiate for condoms or contraceptive use?
Do you have chems*x (s*x during/after substance use)?

There are a couple systems to organise the history. Dr Peek mentioned the 5 P system from the CDC - partners, practices, protection from STI, prior STI, pregnancy intention. To take a more holistic approach, group questions into Arousal, Safety/Respect, and Self-advocacy.
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Fantastic and pragmatic tips from Aruna Venkatesan during this morning’s first talk.

Know what type is skin - hair bearing, hairless, or transitional (non keratinised squamous epithelium) - is where. This knowledge guides differential diagnosis.

Recognise that many people are using an array of products - wipes, sprays, creams, cleansers, and douches - on the ge***al area. Gently ask that they put these all away in a drawer and instead just use the 2 or 3 things we talk about today.

Advise that people can put their favourite emollient in a couple different places in the home…one in the bathroom, one at the bedside table, one in a bag/purse/backpack, and importantly, one in the fridge. Cool is great to reduce itch!

If things aren’t getting better, review 5 possibilities:
Are they using treatment optimally?
Is there superinfection (VVC, HSV, bacterial)?
Is there contact dermatitis?
Is the diagnosis correct, or is there an additional diagnosis?
Is there cancer or it’s precursors?



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All smiles at the reception desk as we welcome friends and colleagues to the 2022 ANZVS scientific meeting.

Our current and former ANZVS Presidents welcome participants to our 2022 biennial scientific meeting. It is fantastic to be together again to connect, learn, and share experiences as professional committed to excellence in VV health care.
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ANZVS Biennial Scientific Conference
11-13 November 2022 at the RACV club
Melbourne, Victoria, Australia
Day 3 - Sunday morning

The scientific program wraps up with a stimulating session on pain.

The amazing A/Prof Susan Evans will first speak to the complexities of pain sensation and perpetuation. Of course the immune system is involved, and that inevitably links into the microbiome, environmental exposures, physiologic & psychologic stressors, and hormonal status.

Yasmin Tan, Sydney-based Gynaecologst, will review medical options for management of v***al pain - thinking about visceral and somatic elements and how to target them.
https://www.whria.com.au/member/physicians/dr-yasmin-tan/

Susan Evans returns to discuss the important prevention work she is doing within the school system. When we see patients in their 20s with 5 or 10 years of pain, our education & health systems have failed.
https://www.drsusanevans.com.au/pelvic-pain/

Ross Pagano, Melbourne-based Gynaecologist and ANZVS Treasurer, will highlight the new, exciting, and controversial topics that drew our attention at the recent ISSVD.

The conference finishes with lunch and we bid most registrants goodbye and see you soon! The small group of registrants for the biopsy workshop stays around for a fun and interactive session.

It is not too late to register! Go to our website and/or email our administrator. Only 5 days to go!

ANZVS Biennial Scientific Conference
Day 3 - Sunday 13 November

Let's talk about s*x on Sunday morning!

Claudia Marchitelli joins us virtually from Argentina to encourage us to address s*xual issues when we see patients with v***al conditions. She brings pragmatism, humour, and passion to every talk she provides and inspires us all to be advocates for our patients' global wellbeing.

Next, Patricia Neumann talks about the strategies pelvic floor physios use to uncover multiple pain aetiologies and empower patients to gain function and confidence.

Finally, the renown Canadian researcher and psychologist Sophie Bergeron joins us virtually to review psychos*xual contributors and causes of v***al pain. It can be difficult to uncover these issues, but in many cases pain improvement will not occur until these problems are identified and addressed.

We are counting down the days - register now and join us next week in Melbourne!

https://www.sophiebergeron.ca/index.php/en/
https://patricianeumann.com.au/

ANZVS Biennial Scientific Conference
Day 2 Saturday 12 November late PM

Saturday's program wraps up with 3 impressive speakers. Gayle Fischer, Sydney-based Dermatologist, addresses the difficulties in distinguishing betweem age-related changes and v***al disorders.

Irene can der Avoort, Gynaecologist from the Netherlands, then speaks to the opposite end of the lifespan - how to recognise lichen sclerosus in children and what to expect as they become young adults.

Finally, Lois Eva, Gynaecologic Oncologist in Auckland NZ, provides her up-to-the-minute insights on HPV-related disease, especially the importance of determining aetiology to guide treatment and surveillance.

Ask your questions to these and previous speakers over drinks and canapes during Happy Hour. We look forward to seeing you soon in Melbourne! Register now on our website if you haven't yet.