Original Article Gynecol Obstet Invest 2015;79:263–268 DOI: 10.1159/000367788
Published online: October 21, 2014
What Differentiates Symptomatic from Asymptomatic Women with Lichen Sclerosus? Pedro Vieira-Baptista a Joana Lima-Silva a João Cavaco-Gomes a Jorge Beires a José Martinez-de-Oliveira b, c a
Serviço de Ginecologia e Obstetrícia, Clínica da Mulher, Hospital de São João, Porto, and b Faculdade de Ciências da Saúde, Universidade da Beira Interior, and c Departamento de Saúde da Criança e da Mulher, Centro Hospitalar Cova da Beira EPE, Covilhã, Portugal
Key Words Lichen sclerosus · Vulva · Dermatoses · Symptoms
the use of absorbents are more commonly present in symptomatic LS patients. Dietary changes and correction of UI might be useful in the control of LS symptoms. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0378–7346/14/0794–0263$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Some series report that up to 40% of lichen sclerosus (LS) patients are asymptomatic [1]. Most of the identified cases are symptomatic, as these patients are more likely to seek help due to more or less intense symptoms (pruritus, burning, dysuria or pain). It is unknown why some women have symptoms while others barely have it or are asymptomatic. Clinical practice shows that the severity of symptoms does not correlate with anatomical changes. The relation between symptoms and the risk of progression to vulval intraepithelial neoplasia and cancer is unknown. The treatment of those who have progressive
No grants were received for the elaboration of this study.
Pedro Vieira Baptista Rua José Pinto Miranda 14 PT–2500-287 Caldas da Rainha (Portugal) E-Mail pedrovieirabaptista @ gmail.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/24/2015 10:26:39 AM
Abstract Aims: To investigate the differences between symptomatic and asymptomatic women with vulvar lichen sclerosus (LS). Methods: Data on file concerning 228 LS patients was retrospectively reviewed. Results: Most patients were symptomatic (193/228; 85%). Worsening of symptoms related to specific food intake was experienced by 26% (48/182) and pork was the most frequently cited (25/48; 52%); worsening at night was reported by 47% (87/185). Being over 50 years at the time of diagnosis or being menopausal were associated with being symptomatic (RR = 2.47, 95% CI: 1.15–5.29 and 6.55, 2.05–20.91, respectively). The same was true for urinary incontinence (UI) (5.23, 1.78–15.42), the use of absorbents (without UI) (3.59, 1.05–12.34) and dyspareunia (5.28, 1.64– 17.0). All patients with a family history of LS were symptomatic. There was no association with hormonal factors or specific vulvar anatomical changes. Conclusions: Pork consumption may be involved in the worsening of symptoms. UI and
% 40 35 30 25 20 15 10 5 0
atrophy, ecchymosis or hyperkeratosis is recommended [2]; however, there is no evidence that it reduces the risk of malignancy. The authors intended to investigate which characteristics or conditions are associated with symptoms or the worsening of it. Special attention was paid to the relation of worsening symptoms and specific food consumption.
Material and Methods The electronic records of 228 patients with a definite diagnosis of LS between October 2009 and October 2012 were retrospectively evaluated. Clinical and/or histological diagnoses were accepted. All patients were observed at least once by one of the authors (P.V.-B.). Cases in which the diagnosis was doubtful were excluded from the analysis. Complete information about demographics and possible factors or associated conditions which can eventually interfere with the presence or worsening of symptoms was obtained by interview at the time of the clinic visit. Statistical analysis was performed using Microsoft Excel® 2011 (Microsoft Corporation©, Redmond, Wash., USA) and IBM SPSS® 20.0 (IBM Corporation©, Armonk, N.Y., USA). This study was approved by the Ethics Committee of the Centro Hospitalar de São João.
Results
During a time period of 3 years (October 2009 to October 2012), 688 patients were referred to our vulvar pathology clinic. Out of these, 228 patients (33%) had a diagnosis of LS (clinical and/or histological). The mean age of the first symptoms was 53 ± 16.2 years; diagnosis was made at a mean age of 59 ± 15.2 years. The mean interval between the beginning of symptoms and diagnosis was 68 ± 11.2 months (fig. 1). 264
Gynecol Obstet Invest 2015;79:263–268 DOI: 10.1159/000367788
>8 5
Age (years)
Table 1. Worsening factors in symptomatic patients
Specific food Yes No
48/182 134/182
26% 74%
25/48 15/48 8/48 6/48 5/48 4/48 4/48 13/48
52% 31% 17% 12% 10% 8% 8% 27%
Pork (ham, pudding, etc.) Spicy food Fried food Fish Olives Acidic fruit (pineapple, oranges) Pepper Others Worsening at night Yes No Other factors Yes No
87/185 98/185
47% 53%
50/186 136/186
27% 73%
Menses Washing Sanitary napkins/panty liners Sex Urination Others
16/50 11/50 10/50 5/50 3/50 11/50
32% 22% 20% 10% 6% 22%
The first symptoms developed after the menopause in 144 out of 228 patients (63%). The vast majority of patients were symptomatic: 193 out of 228 (85%). Among symptomatic patients (table 1), 48 out of 182 patients (26%) reported a worsening of symptoms after consuming a specific food. Pork and pork derivatives (sausage, ham, pudding, etc.) were the most commonly cited. Spicy food, spices, fried food, olives, fish and acidic fruit (pineapple, orange) were also frequently reported. No association was found between the presence of symptoms related Vieira-Baptista et al.
Downloaded by: University of Tokyo 157.82.153.40 - 5/24/2015 10:26:39 AM
Fig. 1. Age distribution (beginning of symptoms and age of diagnosis) of patients with the diagnosis of LS.
21 –2 5 26 –3 0 31 –3 5 36 –4 0 41 –4 5 46 –5 0 51 –5 5 56 –6 0 61 –6 5 66 –7 0 71 –7 5 76 –8 0 81 –8 5
35 >40 >45 >50 >55 >60 >70 Diagnosis after menopause UI and absorbents Use of absorbents UI UI and absorbents Associated conditions Depression Thyroid disease Diabetes mellitus Dyslipidemia Hypertension Dyspareunia Hysterectomy Surgical menopause vs. spontaneous Smoking Hormones Oral contraceptives (ever) Hormonal replacement therapy (ever) Genital changes Hyperkeratosis Fissures Atrophy of the labia minora Phimosis Erosions Edema ‘Cigarette paper’ skin Hyperpigmentation Introital stenosis Perianal involvement ‘Figure-of-8’
RR of being symptomatic
95% CI
χ2 p
3.52 3.47 2.76 2.31 2.47 1.59 1.24 1.54 6.55
0.97–12.77 1.19–10.12 1.14–6.68 1.00–5.34 1.15–5.29 0.75–3.39 0.59–2.59 0.56–4.24 2.05–20.91
Published online: October 21, 2014
What Differentiates Symptomatic from Asymptomatic Women with Lichen Sclerosus? Pedro Vieira-Baptista a Joana Lima-Silva a João Cavaco-Gomes a Jorge Beires a José Martinez-de-Oliveira b, c a
Serviço de Ginecologia e Obstetrícia, Clínica da Mulher, Hospital de São João, Porto, and b Faculdade de Ciências da Saúde, Universidade da Beira Interior, and c Departamento de Saúde da Criança e da Mulher, Centro Hospitalar Cova da Beira EPE, Covilhã, Portugal
Key Words Lichen sclerosus · Vulva · Dermatoses · Symptoms
the use of absorbents are more commonly present in symptomatic LS patients. Dietary changes and correction of UI might be useful in the control of LS symptoms. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0378–7346/14/0794–0263$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Some series report that up to 40% of lichen sclerosus (LS) patients are asymptomatic [1]. Most of the identified cases are symptomatic, as these patients are more likely to seek help due to more or less intense symptoms (pruritus, burning, dysuria or pain). It is unknown why some women have symptoms while others barely have it or are asymptomatic. Clinical practice shows that the severity of symptoms does not correlate with anatomical changes. The relation between symptoms and the risk of progression to vulval intraepithelial neoplasia and cancer is unknown. The treatment of those who have progressive
No grants were received for the elaboration of this study.
Pedro Vieira Baptista Rua José Pinto Miranda 14 PT–2500-287 Caldas da Rainha (Portugal) E-Mail pedrovieirabaptista @ gmail.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/24/2015 10:26:39 AM
Abstract Aims: To investigate the differences between symptomatic and asymptomatic women with vulvar lichen sclerosus (LS). Methods: Data on file concerning 228 LS patients was retrospectively reviewed. Results: Most patients were symptomatic (193/228; 85%). Worsening of symptoms related to specific food intake was experienced by 26% (48/182) and pork was the most frequently cited (25/48; 52%); worsening at night was reported by 47% (87/185). Being over 50 years at the time of diagnosis or being menopausal were associated with being symptomatic (RR = 2.47, 95% CI: 1.15–5.29 and 6.55, 2.05–20.91, respectively). The same was true for urinary incontinence (UI) (5.23, 1.78–15.42), the use of absorbents (without UI) (3.59, 1.05–12.34) and dyspareunia (5.28, 1.64– 17.0). All patients with a family history of LS were symptomatic. There was no association with hormonal factors or specific vulvar anatomical changes. Conclusions: Pork consumption may be involved in the worsening of symptoms. UI and
% 40 35 30 25 20 15 10 5 0
atrophy, ecchymosis or hyperkeratosis is recommended [2]; however, there is no evidence that it reduces the risk of malignancy. The authors intended to investigate which characteristics or conditions are associated with symptoms or the worsening of it. Special attention was paid to the relation of worsening symptoms and specific food consumption.
Material and Methods The electronic records of 228 patients with a definite diagnosis of LS between October 2009 and October 2012 were retrospectively evaluated. Clinical and/or histological diagnoses were accepted. All patients were observed at least once by one of the authors (P.V.-B.). Cases in which the diagnosis was doubtful were excluded from the analysis. Complete information about demographics and possible factors or associated conditions which can eventually interfere with the presence or worsening of symptoms was obtained by interview at the time of the clinic visit. Statistical analysis was performed using Microsoft Excel® 2011 (Microsoft Corporation©, Redmond, Wash., USA) and IBM SPSS® 20.0 (IBM Corporation©, Armonk, N.Y., USA). This study was approved by the Ethics Committee of the Centro Hospitalar de São João.
Results
During a time period of 3 years (October 2009 to October 2012), 688 patients were referred to our vulvar pathology clinic. Out of these, 228 patients (33%) had a diagnosis of LS (clinical and/or histological). The mean age of the first symptoms was 53 ± 16.2 years; diagnosis was made at a mean age of 59 ± 15.2 years. The mean interval between the beginning of symptoms and diagnosis was 68 ± 11.2 months (fig. 1). 264
Gynecol Obstet Invest 2015;79:263–268 DOI: 10.1159/000367788
>8 5
Age (years)
Table 1. Worsening factors in symptomatic patients
Specific food Yes No
48/182 134/182
26% 74%
25/48 15/48 8/48 6/48 5/48 4/48 4/48 13/48
52% 31% 17% 12% 10% 8% 8% 27%
Pork (ham, pudding, etc.) Spicy food Fried food Fish Olives Acidic fruit (pineapple, oranges) Pepper Others Worsening at night Yes No Other factors Yes No
87/185 98/185
47% 53%
50/186 136/186
27% 73%
Menses Washing Sanitary napkins/panty liners Sex Urination Others
16/50 11/50 10/50 5/50 3/50 11/50
32% 22% 20% 10% 6% 22%
The first symptoms developed after the menopause in 144 out of 228 patients (63%). The vast majority of patients were symptomatic: 193 out of 228 (85%). Among symptomatic patients (table 1), 48 out of 182 patients (26%) reported a worsening of symptoms after consuming a specific food. Pork and pork derivatives (sausage, ham, pudding, etc.) were the most commonly cited. Spicy food, spices, fried food, olives, fish and acidic fruit (pineapple, orange) were also frequently reported. No association was found between the presence of symptoms related Vieira-Baptista et al.
Downloaded by: University of Tokyo 157.82.153.40 - 5/24/2015 10:26:39 AM
Fig. 1. Age distribution (beginning of symptoms and age of diagnosis) of patients with the diagnosis of LS.
21 –2 5 26 –3 0 31 –3 5 36 –4 0 41 –4 5 46 –5 0 51 –5 5 56 –6 0 61 –6 5 66 –7 0 71 –7 5 76 –8 0 81 –8 5
35 >40 >45 >50 >55 >60 >70 Diagnosis after menopause UI and absorbents Use of absorbents UI UI and absorbents Associated conditions Depression Thyroid disease Diabetes mellitus Dyslipidemia Hypertension Dyspareunia Hysterectomy Surgical menopause vs. spontaneous Smoking Hormones Oral contraceptives (ever) Hormonal replacement therapy (ever) Genital changes Hyperkeratosis Fissures Atrophy of the labia minora Phimosis Erosions Edema ‘Cigarette paper’ skin Hyperpigmentation Introital stenosis Perianal involvement ‘Figure-of-8’
RR of being symptomatic
95% CI
χ2 p
3.52 3.47 2.76 2.31 2.47 1.59 1.24 1.54 6.55
0.97–12.77 1.19–10.12 1.14–6.68 1.00–5.34 1.15–5.29 0.75–3.39 0.59–2.59 0.56–4.24 2.05–20.91
