This document discusses vestibulitis, a condition characterized by focal erythema and sometimes erosion at the junction of the hymen and vestibule. Women with vestibulitis experience pain with sexual intercourse or tampon insertion due to tenderness in the vestibular area. A careful examination looking for erythema or fissures at the hymenal-vestibular junction can help diagnose vestibulitis. Medical therapies for vestibulitis are generally ineffective as the condition renders the vestibular epithelium more susceptible to damage.

1. A practical approach to
vestibulitis
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Women who have vestibulitis have evidence of focal erythema
and, sometimes, focal erosion at the junction of the hymen and
vestibule. In addition, some patients exhibit vestibular fissures.
52 OBG Management | May 2009 | Vol. 21 No. 5
For mass reproduction, content licensing and permissions contact Dowden Health Media.

2. and vulvodynia
Draw a few basic distinctions and apply simple
strategies to aid your diagnosis and management
of these all-too-common conditions
CASE
David Soper, MD
No relief, despite multiple therapies
Dr. Soper is Professor of Obstetrics
and Gynecology and Vice Chairman A 20-year-old woman is referred to your practice for evalu-
for Clinical Affairs at the Medical ation of persistent dyspareunia. She describes the pain as
University of South Carolina in
“excruciating” and reports that it occurs with attempted IN THIS
Charleston, SC.
ARTICLE
penile insertion.
The author reports no financial
Her symptoms began 1 year ago when she noted some Cyclic vulvovaginitis
relationships relevant to this article.
postcoital soreness at the introitus, as well as external dys- can lead to
uria. The symptoms have become so pronounced that she
dyspareunia
now avoids sexual intercourse altogether. She experiences
page 54
similar pain when she inserts a tampon, wears tight jeans,
or rides a bicycle. She has no history of recurrent vaginitis.
One, simple question
So far, she has tried, sequentially, topical steroids,
vitamin D ointment, topical gabapentin, and oral amitripty-
can aid the diagnosis
line—without improvement.
of vestibulitis
What is the differential diagnosis? And what can you page 56
do to ease her pain?
Essential vulvodynia
responds to medical
A
lthough vulvar pain has many causes, women
who have a chronic vulvar pain syndrome gen- therapy
MOLLY BORMAN FOR OBG MANAGEMENT
erally fall into one of three diagnostic categories page 60
(i.e., McKay’s patterns):
• cyclic vulvovaginal candidiasis
›› SHARE YOUR COMMENTS
How would you diagnose and • vestibulitis
manage the patient described on • essential vulvodynia.1
this page? Drop us a line and let In this case, the diagnosis is vestibulitis, which is
us know.
marked by focal erythema and, in some cases, focal ero-
E-MAIL obg@dowdenhealth.com
sion at the junction of the hymen and vestibule. Clinical
FAX 201-391-2778
findings in women who have vestibulitis are often subtle,
but can be detected with careful examination. CONTINUED ON PA GE 54
o b g m a n a ge me n t .c om Vol. 21 No. 5 | May 2009 | OBG Management 53

3. Vestibulitis and vulvodynia
TABLE How vulvar pain Anatomy of the vulva
is classified The first step in adopting a practical approach
to vulvar pain is developing familiarity with
Generalized
vulvar anatomy. I find it useful to divide the
Involvement of the entire vulva
vulvovaginal anatomy into three discrete areas:
• Provoked (sexual contact, nonsexual
contact, or both) • vulva
• Unprovoked (spontaneous) • vestibule
• Mixed (provoked and unprovoked) • vagina.
The vulvar integument is keratinized and
Localized
Involvement of a portion, or component, contains hair follicles and apocrine glands.
of the vulva, e.g., vestibulodynia, clitorodynia, The epithelium of the vestibule, on the other
hemivulvodynia, etc. hand, is similar to the buccal mucosa: non-
• Provoked (sexual contact, nonsexual keratinized and usually moist, with no ad-
contact, or both) nexal structures. This highly innervated area
• Unprovoked extends from the hymenal ring to Hart’s line
• Mixed (provoked or unprovoked)
(FIGURE 1) and is the primary site of concern
International Society for the Study of Vulvar Diseases13 in women who have a vulvar pain syndrome.
The vagina begins at the hymenal ring
and extends proximally to the cervix. The
FIGURE 1Physical findings may vagina is uniformly normal in patients who
be subtle complain of chronic vulvar pain unless yeast
vaginitis is one of the causes.
Areas of
erythema Cyclic vulvovaginitis can
lead to dyspareunia
When they relapse, Women who have cyclic vulvovaginal can-
women who have didiasis initially complain of symptoms of
cyclic vulvovaginitis yeast vaginitis, e.g., vulvovaginal itching and
tend to experience a cheesy white vaginal discharge. Most wom-
en experience infrequent episodes of yeast
mild irritative
Hart’s line vaginitis, but those who have cyclic candidi-
symptoms and
asis relapse after a short course of topical or
a new complaint of
When vestibulitis is suspected, look for areas of systemic antifungal therapy. When they re-
entry dyspareunia erythema or fissuring at the junction of the hymen
lapse, they tend to experience mild irritative
and vestibule and explore the entire vestibule out
to Hart’s line. symptoms and de novo entry dyspareunia.
PHOTO COURTESY OF DAVID SOPER, MD
Many of these women will have been
treated with intermittent antifungal medica-
tion and antibiotics because their clinician
This article outlines the diagnosis and assumed that a bacterial infection was pres-
management of vestibulitis and essential ent when the antifungal therapy did not solve
vulvodynia, including a basic classification the problem. Another challenge in evaluating
of vulvar pain (TABLE). In the process, it also these women is the inability of point-of-care
sheds light on the tricky diagnosis of cyclic vul- testing to guide the diagnosis—or the omis-
vovaginal candidiasis, which can provoke ves- sion of such testing altogether.
tibulitis in some cases. The basic profile of these patients re-
A careful history, focused physical exami- mains the same, however: relapsing introital
nation of the vulva and vagina, and microsco- symptoms that are relatively mild but lead to
py of the vaginal secretions are the foundation worsening entry dyspareunia, a sign of vestib-
of diagnosis of any vulvar pain syndrome. ulitis. The patient may also report postcoital
54 OBG Management | May 2009 | Vol. 21 No. 5

4. Vestibulitis and vulvodynia
topical or systemic antimicrobial. When she
An overlooked and underestimated affliction returns, vulvovaginal candidiasis can usually
be diagnosed by microscopy and confirmed
As an official entity, the term vulvodynia has been around only 25 by vaginal yeast culture to rule out non-albi-
years. The International Society for the Study of Vulvar Diseases cans Candida. Patients who have recurrent
(ISSVD) defined vulvodynia in 1984 as chronic vulvar discomfort, not- vulvovaginal candidiasis tend to flare pre-
ing that it is characterized in particular by the patient’s complaint of menstrually.
burning, stinging, irritation, or rawness.
Vulvodynia didn’t originate in 1984, of course. But its definition Treatment may be lengthy
was an important first step in identifying a clinical entity that had
Treatment of cyclic vulvovaginal candidiasis
long been ignored by clinicians, primarily because of their inability to
involves an initial course of oral fluconazole
determine a cause, establish a diagnosis, and recommend a specific
course of therapy. In addition, the magnitude of the problem was (150 mg every 3 days for three doses), fol-
woefully underestimated. lowed by suppressive therapy with weekly flu-
A population-based study of 4,915 women in Boston found that conazole (150 mg).2 This treatment is effective
16% of respondents reported either chronic vulvar burning or pain in more than 90% of cases, easing the cyclicity
with contact.11 Hispanic women were more likely than Caucasian and of the patient’s symptoms. However, she may
African-American women to acknowledge such a complaint. be left with some residual vestibulitis and dis-
Similarly, Goetsch found that 15% of patients in her gynecologic comfort with coitus, which may take as long as
practice had vestibular pain and tenderness on examination.12 2 months to resolve. Biweekly application of a
topical steroid of modest strength may help,
such as triamcinalone 0.1% ointment.
soreness and burning after micturition when
the urine drops onto the vestibule (“splash
dysuria”). These symptoms may reflect the Vestibulitis is most common
presence of small vestibular fissures. among young women
Women who have vestibulitis tend to be pre-
Young women Evaluation can be tricky menopausal and young—typically, in their
who have vestibulitis The key to evaluation of a patient with these 20s. They usually complain of worsening
tend to complain complaints is to schedule her appointment pain with coitus, as well as pain with tampon
of progressively once she has been off therapy for at least 2 insertion and tenderness when riding a bike
weeks and has not used any intravaginal or wearing tight jeans, suggesting that touch
worsening pain with
medication during that interval. This drug to the vestibule provokes the pain.
coitus as well as
holiday serves two functions: Despite these other symptoms, however,
other symptoms that
• It eliminates adverse reactions to medi- it is the inability to have vaginal sexual inter-
suggest that touch
cations from the differential diagnosis. course that usually brings the patient to the
to the vestibule • It allows adequate evaluation of vaginal physician. I generally ask a simple question:
provokes the pain secretions, including a reliable vaginal “If you did not engage in sexual intercourse,
culture for Candida species. would you be normal?” In other words, would
During this initial encounter, the exam she avoid the pain if she avoided touch to the
may well be normal. Ask the patient to grade vestibule? Patients who have vestibulitis in-
her vulvovaginal symptoms on a scale of 0 to evitably answer, “Yes!”
10, with 10 representing the worst symptoms
experienced and 0 being a complete lack of “The eye doesn’t see what
symptoms. Many patients at the initial en- the mind doesn’t know”
counter will grade their symptoms as mini- This caveat is important as you examine the
mal, in the range of 2 to 3 out of 10. patient (FIGURE 1, page 54). When vestibulitis
If the exam is normal, ask the patient is present, clinical findings are often subtle;
to return for a repeat evaluation when her careful examination, however, can elicit the
symptoms reach 8 or greater on the 10-point source of the tenderness. Inspect the vulvar
scale, and instruct her not to self-treat with a vestibule carefully circumferentially, and
56 OBG Management | May 2009 | Vol. 21 No. 5

5. Vestibulitis and vulvodynia Vestibulitis and vulvodynia
Improving exert pressure at the junction of the hymen and
contraceptive vestibule using a moistened cotton swab.
As I mentioned earlier, women who have
vestibulitis have evidence of focal erythema and,
success:
sometimes, focal erosion at the junction of the
hymen and vestibule. They also experience ex-
quisite tenderness as the cotton swab presses
against this junction, with the pain most intense
Facilitating choice of in the 3 to 9 o’clock region. Yeast vaginitis should
be ruled out by microscopy and yeast culture.
appropriate and Most patients have avoided coitus for some
time before they see a physician, so vestibular
acceptable contraceptive fissures may not be obvious. The diagnosis of
vestibulitis can be based on Friedrich’s criteria:
methods • severe pain at the vestibule upon touch or
attempted vaginal entry
1.0 • tenderness to pressure localized within the
CME vulvar vestibule
CREDIT • physical findings confined to vestibular ery-
OVERVIEW FREE
Nonuse and misuse of contraception result in the vast majority of unplanned
pregnancies in the United States. The selection of appropriate and acceptable
contraceptive methods can improve adherence. This supplement examines
1.0 CME
CREDIT thema of various degrees.3
the factors that contribute to inconsistent contraceptive behavior and offers
S U P P L E M E N T TO
strategies for assisting patients in the selection and use of methods that best
suit their individual needs and preferences.
EDUCATIONAL OBJECTIVES
Medical therapy is ineffective
At the conclusion of this activity, participants should be better able to:
❚ Discuss factors associated with nonuse/misuse of contraception
and implications for improving adherence
❚ Review the latest safety, efficacy, tolerability, and sustainability data for
current and emerging contraceptive methods
❚ Develop strategies for counseling patients about appropriate
and acceptable contraceptive methods Vestibulitis is a disease that renders the vestibu-
TARGET AUDIENCE
JANUARY 2009
This activity has been designed to meet the educational needs of obstetri-
cians, gynecologists, and other health care specialists involved in the man-
agement of patients who may benefit from contraception.
lar epithelium less resilient and more suscep-
ACCREDITATION STATEMENT
SciMed is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. tible to fissures upon contact. For this reason,
IMPROVING
CREDIT DESIGNATION
medical therapy is ineffective.
SciMed designates this educational activity for a maximum of 1.0 AMA PRA
Category 1 Credit™. Physicians should only claim credit commensurate with
CONTRACEPTIVE
the extent of their participation in the activity.
RELEASE DATE: January 6, 2009
EXPIRATION DATE: January 6, 2010
ESTIMATED TIME TO COMPLETE ACTIVITY: 1.0 hour
DISCLOSURE AND RESOLUTION OF CONFLICTS OF INTEREST SUCCESS: Although a 6-week trial of a topical steroid
SciMed assesses conflicts of interest with its faculty and all individuals who
are in a position to control the content of CME activities. All relevant conflicts
of interest that are identified are resolved by SciMed to ensure fair balance
and scientific objectivity. Facilitating choice of (triamcinalone 0.1% or desoximetasone 0.25%
When asked to report any potential conflict(s) of interest, faculty reported the
following: appropriate and acceptable ointment twice daily) is commonly prescribed, it
Anita L. Nelson, MD
❚ GRANTS/RESEARCH SUPPORT: Barr Pharmaceuticals, Inc. (Duramed Pharma- contraceptive methods
ceuticals, Inc.), Bayer HealthCare Pharmaceuticals (Berlex, Inc.), Wyeth Phar-
maceuticals
❚ SPEAKERS BUREAU/HONORARIA: Barr Pharmaceuticals, Inc., Bayer HealthCare
is rare for a patient to have a response sufficient
Pharmaceuticals, Merck & Co., Inc., Schering-Plough Corporation (Organon
BioSciences), Ther-Rx Corporation, Wyeth Pharmaceuticals
❚ CONSULTANT/ADVISORY BOARD: Barr Pharmaceuticals, Inc., Bayer Health-
Care Pharmaceuticals, Ortho-McNeil Pharmaceutical, Inc., Wyeth Pharma-
› ANITA L. NELSON, MD
Professor, Department of Obstetrics and Gynecology
to restore pain-free coitus.4
ceuticals
David Geffen School of Medicine at UCLA
Andrew M. Kaunitz, MD
❚ SPEAKERS BUREAU/HONORARIA: Barr Pharmaceuticals, Inc., Bayer HealthCare
Pharmaceuticals, Johnson and Johnson (Ortho-McNeil Pharmaceutical,
University of California, Los Angeles
Los Angeles, California
Some patients are adept at applying topi-
Inc.), Merck & Co., Inc., Noven Pharmaceuticals, Inc., Organon BioSciences
❚ CONSULTANT/ADVISORY BOARD: Barr Pharmaceuticals, Inc., Bayer Health-
Care Pharmaceuticals, Johnson and Johnson (Ortho-McNeil Pharmaceutical,
Inc.), Merck & Co., Inc., Noven Pharmaceuticals, Inc., Organon BioSciences
› ANDREW M. KAUNITZ, MD cal 5% xylocaine ointment to the vestibule 15 to
❚ STOCKHOLDER: sanofi-aventis Professor and Associate Chair
All SciMed personnel involved in the development of content for this activity
have no relevant conflicts to report.
The materials for this activity were peer reviewed by Ellen Miller, MD, Clinical
Department of Obstetrics and Gynecology
University of Florida College of Medicine 30 minutes before coitus to ease the discomfort
Jacksonville, Florida
Associate Professor of Medicine, Albert Einstein College of Medicine. Dr. Miller
has no relevant conflicts to report.
INSTRUCTIONS FOR OBTAINING CME CREDIT
associated with intercourse. Another alterna-
There are no fees for participating in and receiving CME credit for this activity.
To obtain CME credit for participating in this activity during the period Janu-
ary 6, 2009 through January 6, 2010, participants must (1) read the educa-
tional objectives and disclosure statements, (2) study the educational activity,
tive is injection of interferon into the vestibule,
(3) complete the posttest by recording the best answer to each question, (4)
complete the evaluation form, and (5) mail or fax the evaluation form with
answer key to SciMed per the instructions on the form.
A statement of credit will be issued only upon receipt of a complete activ-
which can limit the percentage of patients who
ity evaluation form and a completed posttest with a score of 80% or better. Supported by an educational grant from Sponsored by
Participants will be mailed a certificate or statement of credit within 4 to 6
weeks.
DISCLAIMER
require vestibulectomy by almost 50%. Howev-
er, interferon must be injected into the vestibule
The opinions or views expressed in this CME activity are those of the present-
ers and do not necessarily reflect the opinions or recommendations of SciMed
or the commercial supporter. Participants should critically appraise the infor-
mation presented and are encouraged to consult appropriate resources for This supplement was submitted by SciMed and has been edited and peer
three times weekly for 4 weeks.5 Side effects in-
information surrounding any product, device, or procedure mentioned. reviewed by OBG Management.
COPYRIGHT © 2009 DOWDEN HEALTH MEDIA
clude the pain of the needlestick and systemic
fever and flu-like illness from the interferon.
This supplement was sponsored by Vestibulectomy is the
SciMed and supported by an educational treatment of choice
grant from Schering-Plough. Multiple studies suggest 61% to 94% improve-
ment or cure after vestibulectomy.6 A key pre-
dictor of surgical failure is constant vulvar pain
SUPPLEMENT TO
in addition to pain with coitus.7 Such patients
should probably be managed by an expert.
58 OBG Management | May 2009 | Vol. 21 No. 5

6. PELVIC SURGERY
DVD SERIES
FIGURE 2 Excision of the vestibule now available
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FOR ORDERING
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OWN ONE OR
Vestibulectomy involves removal of the entire vestibule
except the part just lateral to the urethral meatus.
ALL 10 SETS IN THE SERIES
PHOTO COURTESY OF DAVID SOPER, MD Review sample clips from these remarkable
state-of-the-art DVDs that utilize detailed surgical
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Before deciding on vestibulectomy, confirm dissections and live surgical demonstrations to
that the patient has had persistent symptoms for teach a variety of pelvic surgical procedures.
more than 6 months. The reason? Spontaneous More than 15 renowned specialists narrate,
remission does sometimes occur within the first covering indications, techniques and how to avoid
6 months of vestibulitis. complications of a variety of pelvic reconstructive
In the OR, after induction of anesthesia, ap- procedures. More than 20 hours of video footage.
ply downward and lateral pressure to the pos-
terior fourchette to bring small fissures to light. DVD Titles:
Vestibulectomy entails removal of the hymen • Sling Procedures from A to Z
and vestibular skin out to Hart’s line. This usually
means removal of all of the vestibule except the • Vaginal Correction of Anterior and Posterior Vaginal
part just lateral to the urethral meatus (FIGURE 2). Wall Prolapse With and Without Vaginal Hysterectomy
Once this tissue is removed, mobilize the • Techniques to Correct Enterocele and Vaginal Vault
vaginal epithelium, as in posterior colporrha- Prolapse
phy, and advance it to cover the surgical defect. • Cystourethroscopy and Urologic Surgery for the
Gynecologist
Postoperative immobilization is required
After surgery, the patient should expect to be • Reconstructive Procedures on the Lower Urinary Tract
somewhat immobilized for 2 weeks and to re- • Retropubic Procedures
quire narcotic analgesia during this time. Heal- • Challenging Cases in Urology and Urogynecology
ing should be apparent by 6 postoperative
• Evaluation of Women With Lower Urinary Tract
weeks, but the suture line at the introitus may
Symptoms With and Without Pelvic Organ Prolapse—
still be slightly tender. I usually recommend that
Including Urodynamic Testing
the patient avoid coitus until the 3-month post-
operative visit. At this visit, the introitus should • Surgical Management of Congenital, Acquired and
no longer be tender. If this is the case, the patient Iatrogenic Lesions of the Vagina and Urethra
can be given the green light for coitus. • Surgery for Posterior Pelvic Floor
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May 2009 | OBG Management 59 www.obgmanagement.com/pelvicdvds

7. Vestibulitis and vulvodynia
usually genital atrophy. Long-term treatment Less is more in the pharmacotherapeutic
with systemic or topical estrogen will usually management of essential vulvodynia. Women
ease coital pain. Surgery is not a mainstay of who do not respond to a lower dosage tend
treatment of dyspareunia in postmenopaus- not to respond to a higher one, either.
al women. (For more on this population, see Another option is gabapentin. It usually
“Postmenopausal dyspareunia: A problem is administered orally but was recently stud-
for the 21st century,” by Alan Altman, MD, in ied in a topical formulation, both of which
the March 2009 issue of OBG Management appear to be effective.9,10
at www.obgmanagement.com.) Counsel the patient that improvement,
not cure, is the therapeutic goal with these
drugs and that her response will be gradual,
Essential vulvodynia is more with improvement usually noticed after 2
common among older women weeks of therapy, continuing until her 6-
Women who have essential (dysesthetic) week revisit. At that time, the dosage can be
vulvodynia tend to be older and postmeno- maintained or increased, depending on the
pausal, although premenopausal women are patient’s response. If the patient is happy with
sometimes affected. These women complain that response, treatment should continue for
of chronic, unremitting, diffuse vulvar burn- 4 months, at which point she can be weaned
ing that is usually not limited to the vestibule. from therapy. Relapse is uncommon.
They may have similar symptoms in the re-
gion of the urethra and rectum. In general, CASE: OUTCOME
dyspareunia is not a major problem. Upon examination, the patient exhibits focal
In women who have essential vulvo- erythema at the junction of the hymen and
dynia, the pelvic examination is absolutely vestibule. Palpation of these areas with a
normal other than the presence of mild geni- moist cotton swab causes extreme tender-
tal atrophy in the postmenopausal patient. ness, recreating the patient’s introital pain.
When the patient There is no evidence of provoked tenderness Microscopy of the vaginal secretions is nor-
has essential and no focal erythema or erosion. mal, and a vaginal yeast culture is negative.
Because she is an excellent candidate for
vulvodynia, the pelvic
exam is absolutely Treatment is medical vestibulectomy, the patient undergoes resec-
Women who have essential vulvodynia are tion of the vulvar vestibule from the hymenal
normal except
not candidates for surgery. Optimal treatment ring to Hart’s line, from the 1 o’clock to 11
for the presence of
of this neuralgia entails the use of low-dosage o’clock positions, and recovers slowly.
mild genital atrophy
amitriptyline (25 to 50 mg nightly) or other At her 6-week postoperative checkup,
in postmenopausal
antidepressants (e.g., venlafaxine, sertraline, the surgical site is healed but tender. At her
women duloxetine).8 I prefer low-dosage sertraline 3-month visit, the introitus is no longer ten-
(25 mg daily) because it has a low incidence of der, erythema has resolved, and she resumes
side effects at this dosage. coital activity.
References
1. McKay M. Vulvodynia. Diagnostic patterns. 6. Landry T, Bergeron S, Dupuis MJ, Desrochers CA. Topical gabapentin in the treatment of local-
Dermatol Clin. 1992;10:423–433. G. The treatment of provoked vestibulodynia: a ized and generalized vulvodynia. Obstet Gynecol.
2. Sobel JD, Wiesenfeld HC, Martens M, et al. critical review. Clin J Pain. 2008;24:155–171. 2008;112:579–585.
Maintenance fluconazole therapy for recurrent vul- 7. Bornstein J, Goldik Z, Stolar Z, Zarfati D, 11. Harlow BL, Stewart EG. A population-based as-
vovaginal candidiasis. N Engl J Med. 2004;351:876– Abramovici H. Predicting the outcome of surgical sessment of chronic unexplained vulvar pain: have
883. treatment of vulvar vestibulitis. Obstet Gynecol. we underestimated the prevalence of vulvodynia? J
3. Friedrich EG Jr. Vulvar vestibulitis syndrome. J 1997;89(5 Pt 1):695–698. Am Med Womens Assoc. 2003;58:82–88.
Reprod Med. 1987;32:110–114. 8. McKay M. Dysesthetic (“essential”) vulvodyn- 12. Goetsch MF. Vulvar vestibulitis: prevalence
4. Nyirjesy P. Is it vestibulitis? Contemp Ob Gyn. ia. Treatment with amitriptyline. J Reprod Med. and historic features in a general gynecologic prac-
2007;52(1):64–73. 1993;38:9–13. tice population. Am J Obstet Gynecol. 1991;164(6
5. Marinoff SC, Turner ML, Hirsch RP, Richard G. 9. Harris G, Horowitz B, Borgida A. Evaluation of Pt 1):1609–1616.
Intralesional alpha interferon. Cost-effective thera- gabapentin in the treatment of generalized vulvo- 13. Moyal-Barracco M, Lynch PJ. 2003 ISSVD ter-
py for vulvar vestibulitis syndrome. J Reprod Med. dynia, unprovoked. J Reprod Med. 2007;52:103–106. minology and classification of vulvodynia: a histor-
1993;38:19–24. 10. Boardman LA, Cooper AS, Blais LR, Raker ical perspective. J Reprod Med. 2004;49:772–777.
60 OBG Management | May 2009 | Vol. 21 No. 5