Androgen Insufficiency May Lead to Vulvar Vestibulitis and Genital Pain

Yael Waknine

October 26, 2004

Oct. 26, 2004 — Androgen insufficiency may result in diminished structure and function of the vestibular glands, including decreased androgen receptor expression, leading to vestibular adenitis and dyspareunia, according to the results of a preliminary study presented last week at the 11th World Congress of the International Society for Sexual and Impotence Research in Buenos Aires, Argentina.

"Vestibulitis is a very common cause of genital pain among women, and there's a subgroup of women [in whom] it's probably related to the use of hormonal birth control pills or hormonal manipulation," Ricardo Munarriz, MD, assistant professor of urology at Boston University School of Medicine in Massachusetts, told Medscape. "That small group of women responds to androgen replacement therapy."

Of 3,000 women with female sexual dysfunction (FSD) evaluated by Dr. Munarriz and colleagues, 13% had dyspareunia, 66% had physical findings of vulvar vestibulitis syndrome (VVS), and 83% had concomitant androgen deficiency.

To evaluate the possibility of a link between androgen deficiency and vestibulitis, the investigators compared vestibular gland tissue excised from patients with VVS (n = 22; mean age, 36 years; 32 sections) with vestibular tissues excised from female cadavers having had no history of vestibulitis (control subjects, n = 5; 9 sections). Patients with VVS had significant dyspareunia as evaluated using the pain domain of the Female Sexual Function Index (mean score, 0.9 ± 0.06; maximal score = 5).

Hematoxylin-eosin staining showed significant inflammation ( P = .00009) and squamous metaplasia in the vestibular specimens of patients with VVS compared with control subjects.

Immunohistochemical staining with antibody anti-estrogen, progesterone, and anti-androgen showed significant decreases in androgen ( P = .014) and progesterone ( P = .00042) receptor expression in vestibular tissue of patients with VVS compared with controls.

"What we found is that the specimens from women who had vestibulitis had significant inflammation, squamous metaplasia, and were completely depleted of androgen receptors — while the controls had no inflammation, and normal staining for androgens," noted Dr. Munarriz. "This makes us believe that there is a link between genital pain due to vestibulitis and androgens.

"We believe that there's a subgroup of women, particularly young women, who as a consequence of being on the birth control pill have very low androgen or testosterone levels," said Dr. Munarriz, noting that these women also tend to have a higher incidence of genital pain. "This may be one of the pathophysiologic mechanisms [explaining] why women on the pill get pain — because they lose their ability to express androgen receptors in the genital tissue," he said.

"On the basis of this premise, it may be that in this subgroup of women genital pain can be effectively treated with hormones," concluded Dr. Munarriz, adding that future studies may evaluate the benefits of testosterone therapy in this population.

The investigators report no pertinent financial conflicts of interest.

ISSIR 11th World Congress: Abstract O74. Presented Oct. 20, 2004.

Reviewed by Gary D. Vogin, MD

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