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Summary These guidelines for the management of vulvodynia have been prepared by the British Society for the Study of Vulval Diseases Guideline Group. They present evidence‐based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines.

A 2% clindamycin vaginal cream, when compared with placebo administered to women with abnormal genital tract flora before 20 weeks' gestation, can reduce the incidence of preterm birth by 60% and hence the need for neonatal intensive care.

Aims: To objectively assess the psychological and psychosexual morbidity of patients with vulvar vestibulitis. Methods: 30 patients with variable degrees of vulvar vestibulitis were recruited from a vulval clinic. Each patient underwent a detailed history and clinical examination. Friedrich's criteria were used for the diagnosis of vulvar vestibulitis. Standardised questionnaires to assess psychological and psychosexual function were completed by the patient before review. These questionnaires were the STAI and a modified psychosexual questionnaire introduced by Campion. Results: Patients experienced considerable psychological dysfunction compared with controls. All aspects of psychosexual dysfunction were affected. Conclusions: When managing patients, psychosexual and psychological issues must be considered in addition to other conventional types of therapy. Vulvar vestibulitis may be a risk factor for developing psychosexual complications including vaginismus, low libido, and orgasmic dysfunction. Consideration of these factors must be an integral part of the management of patients with all chronic vulval conditions.

Women with abnormal smears have an increased risk of developing cervical cancer. During the 8 years following conservative treatment of cervical intraepithelial neoplasia (CIN), their risk of invasive cervical cancer is about 5 times greater than that of the general population. Human papillomavirus (HPV) has been associated with the natural history of both CIN and cervical cancer. To date, there have been no published reports on the predictive value of HPV testing in the treatment outcome of CIN. A prospective, multi-center, cohort study was conducted on women in the Northwest of England who were attending for treatment of CIN. They were asked to complete a questionnaire, which included a detailed smoking history. Pre-and post-treatment HPV testing was performed on cervical biopsies and cervical swab, being taken with the first follow-up smear at 6 months. A nested case-control analysis was performed, cases being de- Carcinoma of the cervix is the leading cause of female cancer mortality in the developing world. 1 In developed countries, the implementation of cervical screening has had a significant impact on the incidence of cervical cancer because of the early detection of the pre-invasive disease and its effective treatment. During the 8 years following treatment of cervical intraepithelial neoplasia (CIN) the risk of invasive cervical cancer for these women remains about 5 times greater than that of the general population of women. 2 Treatment failure of CIN has been found to be associated with the size of the lesion, partially involved excision margins and the degree of CIN. 3-5 Current methods of treatment have all been associated with success rates of 90 -95%. 3,4 All treated women require follow-up to detect residual or recurrent disease, and the ability to distinguish high and low risk women for treatment failure would allow more rational protocols to be developed.Human papillomavirus (HPV) infection, particularly types 16 and 18, has been associated with the occurrence of CIN. 6 Among women with low-grade cervical smear abnormalities, high-risk HPV types are associated with high-grade underlying CIN. [7][8][9] In screened women, persistence of HPV infection has been found to be associated with a greatly increased risk of developing CIN. 10 It has been suggested that, since HPV is detected in many asymptomatic low grade CIN lesions and only a minority of persistent HPV infections progress to cancer, additional factors are necessary if malignant change is to occur. 11 One possible factor may be the exposure to chemical carcinogens such as those present in cigarette smoke. Smoking appears to be the most important factor affecting the progress of CIN after HPV infection. 12 Epidemiological evidence has already implicated cigarette smoking as a possible contributing factor to the development of cervical neoplasia. 13 Smokers have a 4-fold increased risk of developing cervical cancer compared to non-smokers. 14 Smoking is associated with the occurrence of high grade of CIN in the presence of mild dyskaryosis...

Background: In the past few years, increased diagnoses of syphilis have been reported in cities around Britain and Europe. Enhanced surveillance of cases began in 1999 to identify the epidemiology of this increase in Greater Manchester. Methods: Information was collected on all cases of syphilis newly diagnosed in genitourinary medicine (GUM) clinics in Greater Manchester between January 1999 and November 2002. The data collected included demographic information and information about other sexually transmitted infections, sexual behaviour, perception of risk of infection, and awareness of syphilis transmission. Results: The majority of cases identified were white homosexual men resident in Greater Manchester. Of the 414 cases diagnosed, 74% had either a primary or secondary stage of syphilis infection and 37% of cases were HIV positive. High numbers of individuals practised unprotected oral sex despite good awareness of the risk of infection with syphilis. There is evidence that the way people are meeting sexual contacts is changing, with increasing numbers meeting most of their partners through the internet. Conclusions: These findings have implications for targeting interventions. The provision of rapid diagnostic and treatment services is likely to be key for the control of syphilis and potentially of subsequent increases in HIV in the region. We initiated a system of "enhanced surveillance" in February 2000, collecting epidemiological information to establish the extent of infection in Greater Manchester and illuminate the patterns of transmission. METHODSWe devised a form for the collection of epidemiological data, including demographic data, diagnosis, and risk factors and distributed it to each of the 11 GUM clinics in Greater Manchester. Health workers completed one form for each case of syphilis by means of an interview or from case notes where this was not possible. The case definition used was all cases of laboratory confirmed infectious syphilis diagnosed in Greater Manchester from 1999 onwards. For cases diagnosed in 1999 and early 2000, as much data as possible were collected retrospectively from case notes. Completed forms were returned to the North West Office of the Communicable Disease Surveillance Centre (CDSC NW) for collation, data entry, and data analysis. RESULTSBetween January 1999 and November 2002, there were 414 cases of syphilis reported to the enhanced surveillance database by GUM clinics in Greater Manchester. Of these cases, 93% (377/405) were male and 81% (330/405) were homosexual. Of those for whom data were available, 93% of cases (354/382) were born in the United Kingdom, and 82% (310/380) were residents of Greater Manchester. There was no particular residential clustering of cases. The majority of cases (90%; 342/381) were white. The next most significant defined ethnic groups of cases were "Black Caribbean" and "Indian" (each 2.1%; 8/381).The epidemic curve demonstrates some seasonal variation in reporting of infection, with the New Year and summer periods appearing to be key...

Objectives: Vaginal pH is related to hormonal status, and adolescents experience disturbed hormonal patterns following menarche. We assessed hormonal factors and risk of abnormal vaginal pH and bacterial vaginosis (BV) among adolescents attending genitourinary medicine (GUM) clinics. Methods: In a cross sectional study adolescents within 5 years of menarche, (17 years, or with oligoamenorrhoea were recruited. Vaginal pH and BV were assessed and among those not using hormonal contraceptives, estrone-3-glucuronide (E3G) and pregnanediol-3a-glucuronide (P3G) concentrations were measured. Results: Among 102 adolescents, 59.8% (61) had a high vaginal pH (.4.5), which was higher than the prevalence of BV, detected in 33% (34). No association was found between presence of sexually transmitted infections (STI) and vaginal pH. In logistic regression, after controlling for BV and condom use, vaginal pH was positively associated with cervical ectopy (OR = 2.5; 95% CI 1.0 to 6.6, p = 0.05) and STI treatment history (OR = 2.5; 95% CI 0.9 to 6.5, p = 0.07), and negatively associated with use of DepoProvera (OR = 0.1; 95% CI 0.03 to 0.6, p = 0.003) and recent onset (,12 months) of sexual activity (OR = 0.2; 95% CI 0.1 to 0.7, p = 0.004). Among 23 adolescents not using hormonal contraceptives, a high pH occurred more often in abnormal compared to normal menstrual cycles (OR = 10.8; 95% CI 1.4 to 85.4; p = 0.026). E3G concentrations were inversely correlated with vaginal pH in the follicular phase (Spearman: r = 0.51; p = 0.024). Conclusions: Ectopy and abnormal menstrual cycles are common features of adolescence. Their presence is associated with increased risk of abnormal pH, and may also predispose to BV.

Objective: To assess the efficacy of 2% clindamycin vaginal cream (CVC) to treat bacterial vaginosis (BV) in pregnancy. Methods: A prospective, randomized, double-blind, placebo-controlled, tricenter study. Four hundred and four women with BV on Gram stain at their first antenatal clinic visit were randomized to receive a 3-day course of 2% CVC or placebo. The outcome was assessed using an intention to treat analysis at 3 weeks and 6 weeks post-treatment according to three different diagnostic methods based on five criteria (Gram stain and all four elements of clinical composite criteria: vaginal discharge, abnormal vaginal pH, clue cells, amine odor), three criteria (vaginal pH, clue cells, amine odor) or two criteria (clue cells and amine odor) to reflect stringency of diagnosis, historical precedence and government agency recommendations respectively. Results: Using five diagnostic criteria, 18% of CVC patients were cured and 70.8% either cured and/or improved compared to 1.6% and 12% of placebo patients respectively (p < 0.0001). Using three diagnostic criteria, 44.8% of CVC patients were cured and 77.3% were either cured and/or improved compared to 9.3% and 28.8% of placebo patients respectively (p < 0.0001). Using two diagnostic criteria, 75.0% of CVC patients were cured compared to 18.0% of placebo patients (p < 0.0001). Recurrence rates in those CVC patients successfully treated were approximately 6% at 6 weeks post baseline and 10% at 28 to 34 weeks gestation. Conclusions: A 3-day course of CVC appears to be well tolerated by the mother and statistically significantly more efficacious than placebo in the treatment of BV during the second trimester of pregnancy.