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High-grade VIN may be treated with a variety of approaches including topical chemotherapy, laser ablation, wide local excision, skinning vulvectomy, and simple vulvectomy Small, invasive basal cell carcinoma of the vulva should be excised with a wide margin If the VIN is extensive or multicentric, laser therapy or superficial surgical removal of vulvar skin may be required In this way, the clitoris and uninvolved portions of the vulva may be spared Invasive carcinoma confined to the vulva without evidence of spread to adjacent organs or to the regional lymph nodes is treated with wide local excision and inguinal lymphadenectomy or wide local excision alone if invasion is
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Women with endometriosis will complain of pelvic pain, which may be associated with infertility, dyspareunia, or rectal pain with bleeding Initially, pain tends to start 2 7 days before the onset of menses and becomes increasingly severe until flow slackens With increasing duration of disease, pain may become continuous Pelvic examination may disclose tender nodules in the cul-de-sac or rectovaginal septum, uterine retroversion with decreased uterine mobility, cervical motion tenderness, or an adnexal mass or tenderness However, most women with endometriosis have a normal pelvic examination
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6 Analgesics, with or without codeine, may be needed during menses NSAIDs may be helpful
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Endometriosis must be distinguished from PID, ovarian neoplasms, and uterine myomas Bowel invasion by endometrial tissue may produce blood in the stool that must be distinguished from bowel neoplasm Paradoxically, the severity of pain associated with endometriosis may be inversely related to the anatomic extent of the disease Imaging is of limited value Ultrasound examination will often reveal complex fluid-filled masses that cannot be distinguished from neoplasms MRI is more sensitive and specific than ultrasound, particularly in the diagnosis of retroperitoneal lesions However, the clinical diagnosis of endometriosis is presumptive and usually confirmed by laparoscopy
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Surgical treatment of endometriosis particularly extensive disease is effective both in reducing pain and in promoting fertility Laparoscopic ablation of endometrial implants along with uterine nerve ablation significantly reduces pain Ablation of implants and, if necessary, removal of ovarian endometriomas enhance fertility, although subsequent pregnancy rates are related to the severity of disease Women with disabling pain who no longer desire childbearing can be treated definitively with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)
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A Medical Treatment
Medical treatment, using a variety of hormonal therapies, is effective in the amelioration of pain associated with endometriosis However, there is no evidence that any of these agents increase the likelihood of pregnancy Their preoperative use is of questionable value in reducing the difficulty of surgery Most of these regimens are designed to inhibit ovulation over 4 9 months and lower hormone levels, thus preventing cyclic stimulation of endometriotic implants and inducing atrophy The optimum duration of therapy is not clear, and the relative merits in terms of side effects and long-term risks and benefits show insignificant differences when compared with each other and, in mild cases, with placebo Current research for more effective and acceptable long-term medical therapy is focusing on aromatase inhibitors and selective progesterone receptor modulators Commonly used medical regimens include the following: 1 The GnRH analogs such as nafarelin nasal spray, 02 04 mg twice daily, or long-acting injectable leuprolide acetate, 375 mg intramuscularly monthly, used for 6 months, suppress ovulation Side effects of vasomotor symptoms and bone demineralization may be relieved by add-back therapy with norethindrone, 5 10 mg daily 2 Danazol is used for 4 6 months in the lowest dose necessary to suppress menstruation, usually 200 400 mg twice daily Danazol has a high incidence of androgenic side effects, including decreased breast size, weight gain, acne, and hirsutism 3 Any of the combination oral contraceptives, the contraceptive patch, or vaginal ring may be used continuously for 6 12 months Breakthrough bleeding can be treated with conjugated estrogens, 125 mg daily for 1 week, or estradiol, 2 mg daily for 1 week 4 Medroxyprogesterone acetate, 100 mg intramuscularly every 2 weeks for four doses and then 100 mg every 4 weeks; add oral estrogen or estradiol valerate, 30 mg intramuscularly, for breakthrough bleeding Use for 6 9 months 5 Low-dose oral contraceptives can also be given cyclically; prolonged suppression of ovulation will often inhibit further stimulation of residual endometriosis, especially if taken after one of the therapies mentioned above
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