levonorgestrel with the Yuzpe regimen in post-coital contracep-
tion. Hum Reprod 1993;8:389 –92.
17. Webb AMC, Russell J, Elstein M. Comparison of Yuzpe regimen,
danazol, and mifepristone (RU486) in oral postcoital contracep-
tion. BMJ 1992;305:927–31.
18. Trussell J, Rodrı́guez G, Ellertson C. New estimates of the effec-
tiveness of the Yuzpe regimen of emergency contraception. Con-
traception 1998;57:363–9.
19. Barrett JC, Marshall J. The risk of conception on different days of
the menstrual cycle. Population Stud 1969;23:455– 61.
20. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse
in relation to ovulation: Effects on the probability of conception,
survival of the pregnancy, and sex of the baby. N Engl J Med
1995;333:1517–21.
21. Hughes EC, ed. Committee on terminology, American College of
Obstetricians and Gynecologists. Obstetric-gynecologic terminol-
ogy. Philadelphia, Pennsylvania: FA Davis Company, 1972.
Vulvar vestibulitis: Physical
or psychosexual problem?
Jacob Bornstein, MD, Doron Zarfati, MD,
Zeev Goldik, MD, and Haim Abramovici, MD
Objective: To examine whether vestibulitis has a physical or
a psychosexual etiology.
Data Sources: MEDLINE was searched to retrieve publi-
cations dating from January 1981 through June 1998 that
evaluated the outcomes of surgical treatment and the psy-
chosexual theory of the origin of vestibulitis.
Integration: Articles were analyzed for methods of subject
selection and surgery, surgical outcome, and length of fol-
low-up.
Results: A significant decrease in symptoms (complete
responses 1 partial responses) was reported by 89% of 646
women who had perineoplasty for vulvar vestibulitis. Com-
plete resolution of dyspareunia with surgical treatment was
reported in 72% of 512 women whose cases were reviewed in
studies in which complete responses and partial responses
were evaluated separately. Women with vestibulitis did not
differ from the normal population with respect to marital
satisfaction, psychologic distress, or psychopathology. A
suggestion that childhood sexual abuse caused vestibulitis
has not been confirmed. The findings of somatization and
shyness might be explained as results rather than causes of
vulvar vestibulitis.
Conclusion: We do not agree that vestibulitis is a psycho-
sexual problem and one that should not be treated surgi-
cally. A high rate of success can be achieved with proper
surgical treatment. (Obstet Gynecol 1999;93:876 – 80. © 1999
From the Departments of Obstetrics and Gynecology and Anesthesia,
Carmel Medical Center and Rappaport Faculty of Medicine, Technion-
Israel Institute of Technology, Haifa, Israel.
876 0029-7844/99/$20.00
PII S0029-7844(98)00535-3
Address reprint requests to:
James Trussell, PhD
Office of Population Research
Princeton University
Notestein Hall
Princeton, NJ 08544
E-mail: trussell@princeton.edu
Received April 13, 1998.
Received in revised form June 22, 1998.
Accepted July 17, 1998.
Copyright © 1999 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
by The American College of Obstetricians and
Gynecologists.)
Until 1981, dyspareunia was considered a result of
vaginismus, a psychosexual dysfunction that leads to
involuntary contractions of the introital muscles.1,2
Since then, it has been discovered that dyspareunia can
be caused by vulvar vestibulitis, a physical condition
characterized by hyperesthesia of the vestibule.3 Perin-
eoplasty, the surgical removal of the vestibule, a proce-
dure introduced by Woodruff et al,3,4 is one of the
accepted treatments for vestibulitis.
One of the enigmas associated with vulvar vestibuli-
tis is the discrepancy in reported success rates of
surgical treatment, with complete response rates rang-
ing from 40 to 90%.5,6 One publication6 described the
success rate of perineoplasty as low and reported that
better outcomes did not involve valid success assess-
ments. It was suggested that vestibulitis is “a psycho-
sexual problem for which surgery is not the answer.”6
The aim of the present review was to examine
whether vestibulitis has a physical or a psychosexual
etiology by analyzing studies that suggested psychosex-
ual origins of vestibulitis and reports on outcomes of
surgical treatment.
Sources
Publications evaluating surgical treatment of vulvar
vestibulitis and a psychosexual origin of vestibulitis
were selected with a MEDLINE search of the literature
from January 1981 through June 1998, using the search
terms “vestibulitis,” “vulvodynia,” “vaginismus,”
“psychological vaginitis,” “psychosomatic vaginitis,”
“perineoplasty,” “pathology,” and “surgery.” The bib-
Obstetrics & Gynecology
Table 1. Outcome of Surgery for Vulvar Vestibulitis
Outcome
Year of Patient age Length of
Authors study range (y) follow-up (y) CR PR CR 1 PR NR Total

Woodruff et al3 1981 21–78 0.5–5.0 18 18

Woodruff and Parmley4 1983 22–39 0.5–3.0 11 3 14
Woodruff and Friedrich18* 1985 N/A N/A 36 6 2 44
Peckham et al8 1986 N/A 0.5 7 1 8
Friedrich7 1987 18 –75 3 23 15 38
Reid et al9 1988 18 – 80 N/A 13 9 22
Michlewitz et al10 1989 19 – 44 N/A 16 16
Bornstein and Kaufman11 1989 21– 43 0.5–3.0 14 4 2 20
Marinoff and Turner12 1991 N/A N/A 60 11 2 73
Schover et al13 1992 19 – 45 0.1–2.0 18 14 6 38
Mann et al14 1992 N/A 0.5– 4.5 37 12 7 56
Marinoff et al15 1993 21–54 N/A 16 2 1 19
Barbero et al16 1994 18 –39 0.1 19 2 21
Abramov et al17 1994 22– 40 0.3–1.0 7 7
deJong et al6 1995 N/A 3–7 3 3 8 14
Baggish and Miklos5† 1995 N/A 1 13 2 15
Goetsch19 1996 22–35 0.5– 6.0 10 2 12
Weijmar and Schultz et al21 1996 18 –30 0.2–3.0 7 4 2 13
Kehoe and Luesley22 1996 18 –50 0.4 –1.5 22 11 4 37
Chaim et al23 1996 N/A 0.8 – 6.0 15 1 16
Bergeron et al20,24‡ 1997 19 –52 1.1–10.0 24 13 1 38
Bornstein et al25 1997 17–55 1 60 19 79
Westrom and Willen26 1998 2 26 2 28
Total 17– 80 0.2–10.0 371 103 104 68 646
(57%) (16%) (16%) (11%) (100%)
CR 5 complete response; PR 5 partial response; NR 5 no response; N/A 5 not available.
* May include some of the patients reported in Woodruff et al.3,4
†
Including excision of Bartholin glands.
‡
Two publications including reports on the same patients. The results shown in this table are from the more recent study.

liographies of retrieved articles were reviewed for other
articles that were not found in the MEDLINE search.
Discussions with experts in the field also contributed to
the retrieval of relevant studies.
Study Selection
Articles were analyzed with special emphasis on subject
enrollment criteria used. Studies that enrolled women
with vestibulitis diagnosed using Friedrich’s criteria7
were included. The surgical technique also was evalu-
ated. The primary incision was made to a depth of
5 mm along the outer perimeter of the vestibule (Hart’s
line) down to the perineum. The vestibule was excised
cephalad to the hymenal ring. The amount of tissue
removed varied. Few surgeons do partial vestibulecto-
mies, in which only the posterior part of the vestibule is
removed, and most do total vestibulectomies. Perineo-
plasty involved undermining the vaginal mucosa
1–2 cm and advancing that tissue to cover the defect.
Results of operations were categorized as complete
response (intercourse without any discomfort), partial
response (intercourse with some discomfort), and no
response (painful intercourse). The length of follow-up
and articles that presented valid success analysis crite-
ria were evaluated. Reports on the other treatments of
vulvar vestibulitis, such as laser therapy, interferon
administration, and biofeedback training for strength-
ening of the pelvic floor muscles, were not considered
for this analysis.
Studies that analyzed psychosexual characteristics of
women with vestibulitis diagnosed using the accepted
criteria also were collected and evaluated, to examine
whether psychologic disturbances were significant and
whether they were causes or results of vestibulitis.
Studies describing the histopathologic findings were
examined to determine whether tissue samples from
women with vestibulitis had any specific abnormalities.
Results
Surgical Outcome
When all reports on perineoplasty done for vulvar
vestibulitis were summarized (Table 1),3–26 it was found
that 89% of 646 women reported having at least a
significant decrease in symptoms (complete re-
sponses 1 partial responses). Complete resolution of

VOL. 93, NO. 5, PART 2, MAY 1999 Bornstein et al Vulvar Vestibulitis 877
dyspareunia was reported by 72% (371 of 512) of the Other Psychologic Theories
women whose cases were reviewed in studies in which
Two groups of investigators6,27 adopted the psycho-
complete responses and partial responses were evalu-
logic theory to explain the origin of vestibulitis because
ated separately. Age ranged from 17 to 80 years. The
of their observation that in many cases the onset of
length of follow-up was available in 18 of 23 studies and
symptoms was at a time when the women had inter-
ranged from 0.1 to 10.0 years after surgery. Studies that
course without desiring it themselves. In those situa-
assessed surgical outcomes in several follow-up exam-
tions, mechanical irritation due to lack of lubrication
inations showed that those outcomes did not change26
could have started the syndrome. That hypothesis was
or else improved24 over time.
not substantiated, because the investigators did not
The etiology of vulvar vestibulitis is unknown.20 The
document the number of women who had undesired
finding that it is a physical condition and not a psycho-
intercourse and did not develop vestibulitis.
logic disability was significant for treatment plan-
One of these groups of investigators27 suggested an
ning.3,7 A consistent finding in women with vestibulitis
additional etiology: the woman’s continued engage-
was sensitivity localized in the vestibule.7 That pain is
ment in “inadequate sexual behavior,” ie, the woman
reproduced when pressure from a cotton-tipped appli-
chose not to discontinue having intercourse, despite the
cator is applied to the vestibule.5 In most cases, the pain
pain. That assumption ignored the fact that young
is eliminated by surgical excision of the vestibule dur-
women prefer to maintain sexual activity.
ing perineoplasty,3,8,12 emphasizing the physical etiol-
In all studies that examined the psychologic back-
ogy of the disease. However, the theory of a physical
ground, no gross psychopathology or phobic or hypo-
origin of vestibulitis was brought into question by a few
chondriacal behavior was found in the women with
recent studies, which found low success rates of surgi-
vestibulitis.13,31,32 Meana and Binik1 found no differ-
cal treatment.6,27 A new finding, based on responses to
ences between 54 subjects with vulvar vestibulitis and
psychosexual questionnaires, was that of a specific
matched healthy controls on measures of general psy-
somatization disorder commonly diagnosed in women
chologic adjustment (Brief Symptom Inventory) and
with vestibulitis.6,27,28 Those reports led to the proposal
relationship adjustment (Locke-Wallace Marital Adjust-
that vulvar vestibulitis was a psychosomatic condition
ment Scale). They found that women with vulvar ves-
and that surgery should not be considered for treat-
tibulitis were significantly more erotophobic than were
ment.29
controls, with more conservative attitudes toward sex-
uality. The women scored high on the affective distur-
Somatization bance scale, indicating high anxiety and depression.
Those patients had considerable difficulty expressing
The psychosomatic theory was based on findings of a
their feelings, and we believe those abnormalities re-
somatization tendency, detected in many women with
sulted from the disabling sensation experienced by
vulvar vestibulitis.27 “Somatization” refers to patients’
women with chronic pain who, like patients with de-
tendencies to complain of physical symptoms when
pression, were unable to modulate or express intense,
dealing with psychologic stress. Studies found that
unacceptable feelings. Those patients sometimes
women with vestibulitis differed significantly from the
needed counseling and surgery.13,17
normal population in their scores of shyness, somatiza-
Few studies had findings of childhood sexual abuse
tion, and distancing themselves from other people.27,30
in adult women with idiopathic chronic pelvic
The women did not differ from the normal population
pain.25,29,33 In a well-controlled study by Edwards et
in terms of marital satisfaction, levels of psychologic
al,34 89 women with vulvar pain did not have a higher
distress, psychopathology, or extroversion.27,30,31 Their
incidence of sexual or physical abuse during childhood
partners had normal scores for somatization, shyness,
compared with women attending a general dermatol-
marital satisfaction, and levels of psychologic dis-
ogy clinic or women with chronic vulvar symptoms
tress.28,32 We believe that somatization is not the pri-
caused by specific etiologies.
mary disorder in women with vestibulitis but that
women with chronic pain are more outspoken about the
various bodily inconveniences that might affect their
Causes of Surgical Failure
moods or activities. Another reason for overdiagnosis
of somatization disorders in women with vestibulitis is In the study in which it was concluded that vestibulitis
that the Diagnostic and Statistical Manual of Marital has a psychosexual etiology, the conclusion was based
Disorders, 4th edition, (DSM IV) definition of somati- on the finding that 57% of women who had surgery
zation includes features that are present in vestibuli- continued to experience dyspareunia.6 That finding
tis.28 contrasts with other findings of high success rates with

878 Bornstein et al Vulvar Vestibulitis Obstetrics & Gynecology

surgical treatment (Table 1). The discordance between
the favorable outcomes of surgery reported in most
studies and the outcome reported in the article support-
ing a psychosexual etiology might indicate that the
surgical technique in the study was inadequate or that
subject selection was poor. We25 reported that in about
47% of all cases, the anterior and posterior vestibules
are affected by vestibulitis, and failure to remove the
anterior tissue can result in residual dyspareunia. Care-
ful selection of patients was key to the success of
perineoplasty. We showed that in women with vestibu-
litis who present with continuous vulvar pain in addi-
tion to dyspareunia, and in women with dyspareunia
since first coitus, surgical treatment has a higher rate of
failure.25 Data on the character of pain in women in
whom the procedure was not successful were not
included in the report describing a high failure rate.
There were a few other factors that could have biased
the reports of the surgical results in vulvar vestibulitis.
Most studies were not controlled. Clinicians tended to
report and journals tended to accept positive outcomes,
whereas negative outcomes were less likely to be re-
ported. Long-term follow-up data were available in
only a few studies.
Alternative Treatments of Vestibulitis
Because of the studies that claimed suboptimal results
for perineoplasty, nonsurgical treatments were advo-
cated. Those included low oxalate diets with calcium
citrate supplementation,35 biofeedback training for
strengthening of the pelvic floor muscles,32 and admin-
istration of local or systemic interferon injections.36 The
rates of complete response to those treatments were not
higher than the rate for perineoplasty.
Histopathologic Findings
The favorable results of surgery and the histopathologic
examination of tissue support a physical etiology of
vestibulitis. No causative infectious agent was detected,
and a few studies failed to locate an abnormal finding in
the vestibule,37 but a stain for S-100 neural tissue
protein showed increased densities and numbers of
nerve fibers in vestibular specimens from women
treated with surgery for vulvar vestibulitis, compared
with healthy controls.26 Chronic inflammatory infiltrate
was seen frequently in the vestibular mucosa of women
with vulvar vestibulitis38 and was composed mainly of
T lymphocytes, plasma cells,37 and mast cells.23,38 Nerve
bundles are denser in the vestibular inflammatory fo-
ci.26 Specimens from women without vestibulitis did
not show any inflammatory infiltrate.37
VOL. 93, NO. 5, PART 2, MAY 1999
Conclusion
Chronic pain might have a psychologic component and
might be exacerbated by stress. It has been suggested
previously that vestibulitis is a purely psychosexual
problem and cannot be treated surgically. This state-
ment is disputable, as evidenced by the findings of the
studies on surgical therapy reviewed here. In this
review, we also reestablished the theory of a physical
etiology of vestibulitis by reporting high rates of success
with surgical treatment. The psychosexual disturbances
in women with vestibulitis can be secondary to the
physical condition of chronic pain but should not be
considered proof of an exclusively psychopathologic
etiology of vulvar vestibulitis.
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Hormone replacement therapy
and the risk of colorectal
cancer: A meta-analysis
Kavita Nanda, MD, MHS,
Lori A. Bastian, MD, MPH, Vic Hasselblad, PhD,
and David L. Simel, MD, MHS
Objective: To review systematically the association between
hormone replacement therapy (HRT) and the risk of devel-
oping or dying from colorectal cancer.
From the Center for Health Services Research in Primary Care,
Institute for Clinical and Epidemiological Research, Durham Veterans
Administration Medical Center and Duke University Medical Center,
Durham, North Carolina.
880 0029-7844/99/$20.00
PII S0029-7844(98)00424-4
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of vaginitis. Am J Obstet Gynecol 1980;137:600 –3.
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Address reprint requests to:
Jacob Bornstein, MD
Department of Obstetrics and Gynecology
Carmel Medical Center
7 Michal Street
Haifa 34362
Israel
E-mail: mdjacob@tx.technion.ac.il
Received June 26, 1998.
Received in revised form November 2, 1998.
Accepted November 25, 1998.
Copyright © 1999 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
Data Sources: We searched the English-language literature
using MEDLINE, Current Contents, CancerLit, and bibliog-
raphies of selected studies.
Methods of Study Selection: We included studies that
specifically addressed the association of HRT with colorectal
cancer, had adequate controls, and had retrievable risk
estimates. We excluded letters, reviews, and multiple publi-
cations of the same data.
Tabulation, Integration, and Results: Studies were evalu-
ated independently by two of the authors. The exposures of
interest were ever, recent, or former use of HRT, and the
main outcome measures were colon and rectal cancer inci-
dence and mortality. To reduce the risk of a “healthy
estrogen user” bias, we defined recent HRT use as either at
time of assessment or within the previous year. The most
adjusted risk estimates were extracted. We used a random-
effects model to calculate summary relative risks (RRs) and
confidence intervals (CIs). Recent use of HRT was associated
with a 33% reduction in the risk of colon cancer (RR 5 0.67;
Obstetrics & Gynecology