The national rate of people without health insurance dropped to a record low 8% in the first quarter of 2022, according to federal researchers.

 estimated about 26.4 million people lacked health insurance in the first quarter of 2022, down from an annual estimated of 31.6 million people without insurance in 2020. That indicates about 5.2 million people – an estimated 4.1 million adults aged 18 to 64 years, and 1 million children aged 17 years or younger – gained health coverage since 2020.

The figures were in an analysis published Aug. 2 by the Office of Health Policy in the 

Assistant Secretary for Planning and Evaluation

 (ASPE) in the U.S. Department of Health and Human Services (

). APSE credited the administration of President Joe Biden for 2021 actions that built on large reductions in uninsured rates due to the 2014 Affordable Care Act (ACA).

“Overall, these results highlight the significant gains in health insurance coverage that occurred in 2021 and early 2022 associated with the Biden-Harris Administration’s policies to support health insurance expansion,” the report said. “These gains build on the large reductions in the uninsured rate that occurred after the implementation of the Affordable Care Act (ACA) in 2014, which research demonstrates produced improved health outcomes, better access to care, and improved financial security for families.”

Before 2022, the previous record low uninsured rate was 9% in 2016, for the annual rate. The lowest quarterly estimate was 8.6% in the first quarter of 2016, though the report noted quarterly estimates are more volatile due to smaller sample sizes.

About 5.4% of adults aged 18 to 64 years reported having ACA Marketplace coverage in early 2022, up about 2 million people from the 4.4% Marketplace coverage rate of 2020.

The American Rescue Plan,the administration’s response to the economic woes caused by the COVID-19 pandemic, included enhanced subsidies for people seeking insurance through the Marketplace at HealthCare.gov. The subsidies were retroactive to the start of 2021, boosted the size of premium tax credits for people with incomes between 100% and 400% of the federal poverty level (FPL), and extended tax credits to those with incomes above 400% of the FPL for the first time, the report said.

The Inflation Reduction Act, introduced in the Senate, would extend ACA Marketplace insurance subsidies through 2025.

“And I'm hopeful that with Congressional action we can continue the work to lower costs for more Americans by both extending the enhanced Affordable Care Act tax credits that have helped drive the uninsured rate to an all-time low and increasing the affordability of prescription drugs for Medicare beneficiaries – reducing their cost sharing and allowing Medicare to negotiate a better deal on prescription drug prices,” HHS Secretary Xavier Becerra said in a statement.

Without an extension, there have been predictions that millions of people will face premium increases for Marketplace plans, leading to a decline in overall health care spending. Regardless of subsidies, at least one report has forecasted a spike in 2023 premiums due to inflation.

Additional factors for the declining uninsured rate included the continuous enrollment provision in Medicaid for adults aged 19 to 64 with incomes less than 138% of the FPL.

Five states expanded Medicaid for adults in 2019 and 2020. From 2018 to 2020, the most recent year data are available, those states had the largest decreases in uninsured rates: Idaho (-8.4%), Virginia (-7.2%), Maine (-4.9%), Nebraska (-2.8%), and Utah (-1.4%).

Two states that expanded Medicaid in 2021 posted increases in the rates of uninsured: Missouri (1.7%) and Oklahoma (2.9%). The report did not explain why.

Among the 50 states and the District of Columbia, only four – Washington D.C., Massachusetts, Rhode Island and Vermont – had single digit uninsured rates for those who qualify for Medicaid.

 that “Medicaid expansion was shown to have improved preventive care and financial security for adults with disabilities.”

This article originally appeared on Medical Economics®. 

Articles

More people getting health coverage, but 26.4 million still don’t have it.

Rate of people without health insurance hits record low

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With the summer months sweltering on, the editors and contributors of Contemporary OB/GYN® have been hard at work carefully crafting a great issue that touches upon a variety of subjects within obstetrics and gynecology.

Best practices on discussing birth control for adolescents.

How much money are you losing in unnecessary meetings?

Tips to avoid wasting time and optimize meetings you do need.

Follow along to read articles as they go live. 

A look at the cover of this month's issue of Contemporary OB/GYN. 

In this issue: August 2022

The Northeast, Florida and Arizona are the nation’s hotspots for private equity (PE) firms to acquire 

 examined geographic trends of private equity acquisitions of physician offices specializing in dermatology, gastroenterology, ophthalmology, obstetrics/gynecology (OB/GYN), orthopedics, and urology. Among those, less than 10% of physicians worked in PE-acquired practices, as of 2019, based on figures from the IQVIA OneKey database, compiled with the American Medical Association Physician Masterfile and other data.

, good and bad, of PE investments in physician practices. The study did not attach financial values to PE transactions and did not examine 

, but it did refer to potential price hikes if market competition dries up.

“Because some PE acquisitions consolidate physician practices into larger organizations, geographic concentration of PE penetration may be associated with reduced physician competition, which could lead to increased prices,” the study said. “If PE acquisitions induce practice consolidation among remaining independent practices with financial pressures, this spillover effect may further hinder competition, underscoring the importance of monitoring practice consolidation and the ownership and regulatory environment of acquisitions.”

The research letter, “Geographic Variation in Private Equity Penetration Across Select Office-Based Physician Specialties in the U.S.,” was published earlier this year in 

The study found in 2019, there were 97,094 physicians in the six specialties and 4,738, or 4.9%, worked in PE-acquired practices, the study said. PE penetration was:

7.5% for dermatology, or 851 of 11,324 physicians

7.4% for gastroenterology, or 845 of 11,484 physicians

6.5% for urology, or 492 of 7,609 physicians

5.1% for ophthalmology, or 741 of 14,493 physicians

4.7% for OB/GYN, or 1,325 of 28,493 physicians

1.9% for orthopedics, or 460 of 23,891 physicians

Based on state and hospital referral region data, PE penetration was greatest in the Northeast at 6.8%, or 1,270 of 18,708 physicians, and lowest in the Midwest at 3.8%, or 638 of 16,613 physicians. PE penetration was highest in:

Washington D.C., 18.2 %, or 188 of 1,031 physicians

Arizona, 17.5%, or 326 of 1,866 physicians

New Jersey, 13.6%, or 464 of 3,49 physicians

Maryland, 13.1%, or 195 of 1,488 physicians

Connecticut, 12.6%, or 212 of 1,688 physicians

Florida, 10.8%, or 741 of 6,852 physicians

This article originally appeared on Medical Economics

Consolidation, “reduced physician competition,” could lead to price increases for patients.

Geographic trends emerge for private equity firms acquiring physician offices

Brian Iriye, MD, is former president of the SMFM and president of Hera Women's Health, and Managing Physician of the High Risk Pregnancy Center.

Jim Keller, MD, is vice president of medical management at Advocate Trinity Hospital and chair of the practice management division of the Society for Maternal-Fetal Medicine (SMFM).

Those of us in management have come to recognize meetings as an inevitable part of our workday. The greater your administrative to clinical time, the greater the amount of time you will spend in meetings both as a meeting participant and as a leader. the increased number of remote meetings has had a negative impact as the threshold for creating a meeting decreased and the ease of inviting participants to meetings increased. The cost of meetings is rarely considered, but the next time you are at meeting, think about this: It is not unreasonable to estimate that an hourlong meeting of clinicians may cost close to $1000 in missed clinical revenue. It is imperative that meetings are managed as effectively as any common clinical scenario.

Whillans et al describe 6 pitfalls that lead to excessive meetings

1. Meeting FOMO (fear of missing out): What will our colleagues, or worse, our bosses think of us declining an invitation for a meeting of marginal necessity? this is rooted in the belief that just being present is being productive.

2. Selfish urgency: As leaders, not everything that we think is important justifies disrupting others’ days or adding an extra hour to the workday.

3. Meeting as a commitment device: using a meeting solely to establish a deadline is not a great use of time.

4. The mere urgency effect: This is where we feel better for completing a task, no matter what the value is. An example is low-value regular meetings. If we complete a series of meetings, we feel we have accomplished something, even if we have not.

5. Meeting amnesia: this is the meeting to review what was accomplished (or not) at the previous meeting. A much better tactic would be real-time debriefs or distribution of meeting summaries.

6. Pluralistic ignorance: Chances are we are not the only one who recognizes that a standing meeting is a waste of time. Open dialogue can remove a standing meeting from our calendars. Action plans and end goals are neededthere is a lot of science around effective meetings. 

A review of 100 articles on the subject came up with some tips

: Do you really need a meeting? Can a quick call or email suffice? Invite the smallest number of people required. This not only makes the meeting easier to manage and more effective but will greatly facilitate its scheduling in a timely manner. Build an agenda and stick to it. This seems so simple yet is probably the most common reason a meeting succeeds or fails. Everyone should know the end goal of the meeting. An agenda describes the process, but an end point will drive efficiency. It is a great tool for refocusing those who may be derailing the meeting. End with an action plan and a follow-up deadline for items on the agenda. this will effectively reduce the frequency of a second, less valuable meeting. Allow participants to leave a meeting if they feel that they are not contributing or that the meeting is not of value. After evaluating whether a meeting is necessary, deciding who needs to attend, and establishing an agenda and goals, the next decision point is the duration of the meeting. Meeting content seems to follow the laws of natural gas: It will expand to fill the available allotted time. scheduling your meetings for shorter periods of time will force discipline around roles and agendas and will free your teams up to be more productive in other spaces. 

Lucy Handley takes the 30-minute meeting 1 step further and promotes a 15-minute meeting.

 The purpose of the 15-minute meeting is 2-fold. The 15-minute meeting is not just about going more quickly. It is about prework. The foundation of this prework is asynchronous communication. A shorter meeting requires individuals to read materials sent prior to the meeting so they need not be reviewed. 

One highly creative approach is a brief video sent premeeting by the organizer. this shows that the organizer values the participants’ time and will lead to greater focus. Although the 15-minute meeting is not for every subject, it can be a great strategic tool. Make the most of online meetingsAlthough the foundation of meetings remained unchanged when they moved online via Zoom, Microsoft teams, etc, there still are special considerations. 

 discussed the potential for remote meetings to be draining rather than energizing to those working remotely, along with reasons and tactics for mitigating the risk of disengagement. Although the discomfort of constantly being on display and having to look at a screen of others throughout a meeting is something we can get used to, other issues such as multitasking during meetings will always hinder the productivity of a session. Although some have advocated mandatory “cameras on,” constantly being present on screen can increase the fatigue of a remote workday.

 Suggestions for improving appearance on remote video calls include both technical and physical strategies. Computers’ imbedded microphones and cameras rarely compare in quality to many inexpensive combined apparatuses, which are easy to install. Individuals should be aware of posture and facial expressions, watch out for lighting mishaps, and make sure they are well lit from the front. Unlike an add-on camera/microphone, which is essential, professional lighting is not something everyone needs. But it is important to ensure there is not an intense light source behind you, which can cause you to appear as a silhouette.

In a recent Harvard Business Reviewarticle,

 Rae Ringel wrote that “I’m going to give you 10 minutes of your life back” is a phrase to stop using. Ringel points out that if a meeting is run properly, one might be able to say, “Because everyone was so productive, we’re done 10 minutes early. Thank you so much for your presence and participation.” That’s the kind of meeting you should be aiming for.  

1. Whillans A, Feldman D, Wisniewski D. The psychology behind meeting overload. Harvard Business Review. November 12, 2021. Accessed June 29, 2022. https://hbr.org/2021/11/the-psychology-behind-meeting-overload

2. LePage E. Tips for effective meetings we learned from reading 100 articles. Unito. January 13, 2020. Accessed June 29, 2022. https://unito.io/blog/running-effective-meetings-tips/

3.Handley L. The rise of the 15-minute meeting —and how to run one. CNBC. January 25, 2022. Accessed June 29, 2022. https://www.cnbc.com/2022/01/25/the-rise-of-the-15-minute-meeting-and-how-to-run-one.html 

4.Discovery RSM. How to have effective zoom meetings—and make them less boring. Forbes. March 4, 2021. Accessed June 29, 2022. https://www.forbes.com/sites/rsmdiscovery/2021/03/04/how-to-have-effective-zoom-meetings-and-make-them-less-boring/

5.Gabriel AS, Robertson D, Shockley K. Research: cameras on or off? Harvard Business Review. October 26, 2021. Accessed June 29, 2022. https://hbr.org/2021/10/research-cameras-on-or-off

6.Ringel R. Please stop using these phrases in meetings. Harvard Business Review. January 11, 2022. Accessed June 29, 2022. https://hbr.org/2022/01/please-stop-using-these-phrases-in-meetings4 / 466%

Tips to avoid wasting time and optimize meetings you do need.


Melissa M. Mauskar, MD, is an associate professor of dermatology and obstetrics and gynecology at UT Southwestern Medical Center in Dallas, Texas. She is the founder and director of the Gynecologic Dermatology clinic at UT Southwestern.

Hunter J. Pyle is a fourth-year medical student at the UT Southwestern Medical Center in Dallas, Texas.

Audrey K. Rutherford, MD, is a dermatologist who recently graduated from the dermatology residency program at UT Southwestern in Dallas, Texas. Her current practice is in Salt Lake City, Utah, where she treats women with vulvar dermatoses as well as practices general medical, surgical, and cosmetic dermatology.

Recognizing and appropriately managing common vulvar conditions is essential to preserve patient quality of life and prevent irreversible architectural sequelae. Patients with vulvar dermatoses often report a significant delay from symptom onset to diagnosis. This delay is multifactorial and includes patient and provider reluctance to discuss vulvovaginal or other intimate symptoms. In addition, most women do not examine their vulvas.

Results of a study showed that only 15% of participants were able to correctly sketch vulvar anatomy, 67% had not heard of vulvar self-examination, and 61% approached their genitalia with feelings of shame and embarrassment.

 It is important that providers be comfortable initiating these conversations to prevent diagnostic delay and to give patients accurate information and timely treatment.

Using the correct terms allows providers to develop a wide differential diagnosis 

. An important concept in vulvovaginal dermatology is lichenoid eruption, a diverse group of inflammatory skin diseases sharing common morphology and/or histopathology. Distinguishing among the various lichenoid conditions of the genitalia, including vulvar lichen sclerosus (VLS), vulvovaginal lichen planus (VLP), and vulvar lichen simplex chronicus (LSC), is important because optimal treatments vary. 

Figure 1. Select Dermatology Terminology. 

Although all 3 conditions may present primarily with pain or pruritus, features such as anatomic involvement, risk factors, and associations may differ. VLS and VLP are primary cutaneous disorders, whereas vulvar LSC is a secondary skin condition resulting from another underlying dermatosis, infection, or psychological or neurologic condition. VLS primarily affects external genitalia, whereas VLP may affect both the vulva and vagina.

VLS is a chronic, often progressive dermatologic condition that involves the anogenital region. The prevalence of VLS is not well established, though it is likely an underrecognized and undermanaged condition. Results of large cohort study showed an estimated prevalence in the United States of 0.05%, with 79% of diagnoses in women between the ages of 45 and 65 years but 16% of diagnoses in women between the ages of 18 and 44 years.

 Most patients present with vulvar pain, pruritus, or irritation, but patients may be asymptomatic. Patients eventually diagnosed with VLS may have yeast infections for years 

Figure 2-1. Pustules on an erythematous base in a patient with vulvovaginal candidiasis.

Figure 2-2. Hypopigmented macules in a patient with vulvar lichen sclerosus.

Early detection of VLS is critical to preventing irreversible architectural sequelae and vulvar squamous cell carcinoma (SCC). Skin changes that may be evident upon vulvar inspection include white, atrophic papules that may coalesce into plaques, often affecting the labia minora or majora 

Figure 2-3. Typical hypopigmented tissue paper wrinkling in a patient with vulvar lichen sclerosus. (Figures provided by author)

Early VLS may have a nonspecific presentation, so a high degree of suspicion must be maintained. Varying degrees of architectural change may be present in later disease stages. It is important to note indurations and small erosions, which could be signs of SCC, even in younger patients. First-line treatment is early use of a superpotent topical corticosteroid with continued topical corticosteroid for maintenance therapy. Patient education emphasizing treatment adherence is critical. In a study that spanned 8 years, patients adherent to topical corticosteroid treatment did not develop SCC or precursor vulvar intraepithelial neoplasia (VIN), and adhesions and scarring developed in only 3% of patients.

 Reports of symptomatic control also were higher in adherent patients. In contrast, in patients only partially adherent with treatment, 5% developed SCC or VIN and 40% developed adhesions
and scarring.

VLP is an inflammatory condition and subtype of lichen planus (LP) that most commonly affects women between 50 and 60 years of age.

 Although the incidence and prevalence of VLP is unknown, most women with LP have genital lesions.

 Most frequently, patients will present with soreness, pruritus, or genital burning. 

Allergic and irritant contact dermatitis of the vulva

Allergic and irritant contact dermatitis (ACD/ICD) frequently occur concomitantly with other vulvar conditions as preexisting dermatosis impairs skin barrier function. In patients with vulvar ACD, the most common concomitant vulvar diagnoses are VLS followed by LSC.

 This may complicate the clinical picture and lead to diagnostic and management delays. Therefore, vulvar ACD/ICD should be considered when patients with vulvar disease are not improving with standard treatment.

Figure 2-4. Introitus erosions with surrounding lacy/reticular border in a patient with erosive vulvovaginal lichen planus.

Vulvar ICD may occur acutely or, more commonly, chronically. Symptoms in vulvar ACD may become apparent 1 to 2 days after allergen exposure, but commonly the exposure is unrecognized and may only slowly produce symptoms and eruption. This frequently leads to difficulty in identifying the culprit allergen. Patients with ACD/ICD often present with nonspecific vulvar pruritus or burning. Skin changes in vulvar ACD/ICD are similar and include erythema, edema, vesicles, bullae, and oozing. Thus, clinical differentiation of vulvar ACD/ICD is not reliable. The diagnosis of vulvar ICD is based on history and establishment of a potential irritant, whereas vulvar ACD may be established with patch testing.

Patients with vulvovaginal symptoms have often tried various topicals for symptom resolution before seeking medical attention. Common vulvar irritants include body fluids, hygiene or personal care products, heat, excessive bathing, medications, soaps, and detergents.

 The most commonly identified allergens in ACD are fragrances, preservatives, and medications including neomycin and topical anesthetics.

 Patients may have an allergy to topical corticosteroids,

 which are an important first-line treatment for many vulvar dermatoses 

ACD/ICD treatment includes discontinuing potential irritants and allergens, using petroleum on erosions, and educating patients. Patients should be counseled on the importance of cleaning the vulva with lukewarm water without harsh or fragranced soaps, cleansers, or detergents, and using sitz baths for additional symptomatic relief. Topical corticosteroid ointments may be used in severe or chronic disease, and antihistamines may be used for pruritus. Patients may benefit from a dermatology referral for patch testing to identify possible culprit allergens, which is a more appropriate testing modality to identify contact allergens than the skin prick test commonly performed by allergist physicians.

Figure 2-5. Erythematous thickened, corrugated plaques with accentuation of skin markings on the labia majora and inguinal folds characteristic of lichenification found in lichen simplex chronicus. There is also a thin white scale on the leftinguinal fold. (Figures provided by author).

LSC is a reactive skin disorder secondary to chronic skin rubbing or scratching, often in response to persistent pruritus or irritation, regardless of primary problem. It results in secondary changes of skin including thickening and lichenification 

, with a moderately well-defined scaly plaque. Patients with other vulvar dermatoses often develop LSC in response to chronic scratching. Patients with LSC can pose a diagnostic challenge as primary skin conditions cannot be appropriately diagnosed until there is improvement in LSC symptoms and cutaneous changes. LSC is typically a clinical diagnosis, and management centers on disrupting the itch-scratch cycle, in which pruritus leads to scratching, which perpetuates and worsens inflammation. First-line medical treatment often includes a short course of medium-potency topical corticosteroid to promote active lesion resolution. Upon treatment of LSC, an underlying primary vulvovaginal dermatosis may be more readily identifiable and addressed.

Genitourinary syndrome of menopause (GSM), formerly called vulvovaginal atrophy or atrophic vaginitis, refers to a collection of signs and symptoms that occur in menopausal women secondary to decreased stimulation of estrogen-sensitive tissues, including the vulva, vagina, urethra, and bladder. GSM is very common. In fact, vulvovaginal symptoms occur in 39% to 51% of postmenopausal women, with the majority having moderate to severe symptoms, and one-third stopping sexual activity because of their symptoms.

 Unfortunately, many women do not recognize vulvovaginal atrophy and are reluctant to discuss vaginal or sexual symptoms with health care professionals.16 Most women with GSM believe that their vaginal symptoms are a normal part of aging.

 Symptoms seen in GSM include genital dryness, discomfort, burning, dyspareunia, dysuria, urinary incontinence, and recurrent urinary tract infections. Physical changes may include a vaginal epithelium that is a paler pink hue with decreased rugation, diminished pubic hair, decreased turgor and elasticity of the vulva, and minimization of the labia minora. GSM is a clinical diagnosis. Women have a strong desire for health care professionals to initiate conversations regarding GSM.16 First-line treatment includes vaginal moisturizers, personal lubricants, and low-dose vaginal estrogen. Of note, multiple studies have shown no increase in risk of cardiovascular disease or cancer with low-dose vaginal estrogen use.

 In addition, low-dose vaginal estrogen has minimal systemic absorption and does not increase plasma estradiol to premenopausal levels, study results show.19 In cases of advanced symptoms, pelvic physical therapy may be beneficial, particularly for urinary incontinence
and dyspareunia.

Talking to a patient about vulvovaginal concerns

Intake Questionnaire, Select Example Questions

Before the clinic visit, intake questionnaires provide the patient with space to answer sensitive questions 

. During evaluation, review the patient’s hygienic practices and product usage. Patients should be asked whether they engage in a vulvar washing or cleaning practice. In our society, where patients unfortunately are taught that their vulvas are unclean, patients may believe that symptom resolution is only a matter of washing more thoroughly or vigorously. Such aggressive cleaning can lead to recalcitrant vulvar disease. Also note any products that patients may be using after toileting, such as wet wipes, that could lead to vulvar ACD/ICD. In reviewing medication and product usage, document the location of genital application. This can be completed during the exam with direct patient demonstrations by having the patient apply plain petroleum jelly to herself as if it were medication. Frequently patients do not directly visualize where they are applying products or are using inappropriate amounts of topical therapies, which may lead to inadequate undertreatment of some locations or inappropriate overtreatment of others.

Prior to physical examination, have a chaperone or assistant enter the room and obtain patient verbal consent. Patient communication before and during examination increases participation and facilitates patient control and autonomy. For new patients or those with notable vaginal discharge, obtain wet and KOH preps to assess for infection and diagnostic clues (such as parabasal cells in GSM). Using a hand mirror allows patients to see where medication should be applied. The patient’s position on the examination table is crucial to optimize their viewing of medication application. The patient may use petroleum jelly at this point to demonstrate how they apply medication, which provides another opportunity for redirection or educational intervention if application is incorrect.

A vulvar biopsy may be needed to diagnose conditions when the clinical diagnosis is uncertain. Biopsy type depends on clinical impression. Shave biopsy may be used for suspected VLS or VLP, whereas punch biopsy should always be used for ulcerations or suspected malignancy. Get a biopsy for suspected VLS in the crinkly area, suspected VLP at the edge of defect such that normal skin is included, and suspected malignancy in the center or border of the lesion.

During the management portion of the clinic visit, patient handouts and literature reinforce information covered during the clinic visit, and a photograph of the patient’s genital area may be obtained and annotated for patient medical or personal records after patient consent. Reviewing this photograph with the patient allows them to clearly see affected areas and visualize where topical medications should be applied. The photograph may be annotated to specify the location, amount, and frequency of topical medication application 

Figure 5. Annotated patient photograph (Figure provided by author)

After the clinic visit, give the patient this annotated photograph to take home to use as a guide for treatment application. At future clinic visits, this initial photograph may be reviewed to demonstrate clinical improvement or changes, and a new photograph may be taken and annotated to help communicate any necessary adjustments to areas of topical application.

At subsequent visits, the differential should be revisited, especially if the patient is not improving, as treatment failure may be the result of missed diagnoses. A patient may have more than 1 condition concurrently affecting the vulva and vagina, which may be causal or only associated with one another. It is equally important to rediscuss exposures, hygiene, and medications, as patient habits may evolve and complicate conditions or be misinterpreted as flares of primary processes when instead they represent a new secondary or concomitant process, such as development of new ICD. 

1.Preti M, Selk A, Stockdale C, et al. Knowledge of vulvar anatomy and self-examination in a sample of Italian women. 

. 2021;25(2):166-171. doi:10.1097/LGT.0000000000000585

2.Melnick LE, Steuer AB, Bieber AK, Wong PW, Pomeranz MK. Lichen sclerosus among women in the United States. 

. 2020;6(4):260-262. doi:10.1016/j.ijwd.2020.05.001

3.Lee A, Bradford J, Fischer G. Long-term management of adult vulvar lichen sclerosus: a prospective cohort study of 507 women. 

. 2015;151(10):1061-1067. doi:10.1001/jamadermatol.2015.0643

4.Cooper SM, Wojnarowska F. Influence of treatment of erosive lichen planus of the vulva on its prognosis. 

. 2006;142(3):289-294. doi:10.1001/archderm.142.3.289

5.Kennedy CM, Galask RP. Erosive vulvar lichen planus: retrospective review of characteristics and outcomes in 113 patients seen in a vulvar specialty clinic. 

6.Lewis FM, Shah M, Harrington CI. Vulval involvement in lichen planus: a study of 37 women. 

7.Zendell K, Edwards L. Lichen sclerosus with vaginal involvement: report of 2 cases and review of the literature. 

. 2013;149(10):1199-1202. doi:10.1001/jamadermatol.2013.4885

8.Bradford J, Fischer G. Management of vulvovaginal lichen planus: a new approach. 

. 2013;17(1):28-32. doi:10.1097/LGT.0b013e318258bf5b

9.Fairchild PS, Haefner HK. Surgical management of vulvovaginal agglutination due to lichen planus. 

. 2016;214(2):289.e1-289.e2. doi:10.1016/j.ajog.2015.08.070

10.Trivedi MK, Woodruff CM, Kornik R, Botto N. Patch testing in vulvar allergic contact dermatitis. 

. 2018;29(2):95-96. doi:10.1097/DER.0000000000000345

11.Schlosser BJ. Contact dermatitis of the vulva. 

. 2010;28(4):697-706. doi:10.1016/j.det.2010.08.006

12.Warshaw EM, Furda LM, Maibach HI, et al. Anogenital dermatitis in patients referred for patch testing: retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 1994-2004. 

. 2008;144(6):749-755. doi:10.1001/archderm.144.6.749

13.Lewis FM, Shah M, Gawkrodger DJ. Contact sensitivity in pruritus vulvae: patch test results and clinical outcome. 

14.Dumycz K, Osinka K, Feleszko W. Contact allergens in topical corticosteroid vehicles: analysis of product composition. 

. 2017;76(4):254-255. doi:10.1111/cod.12693

15.Haefner H. The gynecologist’s guide to steroid use. February 27, 2015. Accessed July 11, 2022. https://dokumen.tips/documents/gynecologists-guide-steroid-useppt-2242015-2-steroids-a-manage-not-cure-dermatologic.html

16.Krychman M, Graham S, Bernick B, Mirkin S, Kingsberg SA. The Women’s EMPOWER survey: women’s knowledge and awareness of treatment options for vulvar and vaginal atrophy remains inadequate. 

. 2017;14(3):425-433. doi:10.1016/j.jsxm.2017.01.011

17.Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. 

. 2018;26(6):603-610. doi:10.1097/GME.0000000000001284

18.Crandall CJ, Hovey KM, Andrews CA, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. 

. 2018;25(1):11-20. doi:10.1097/GME.0000000000000956

19.Santen RJ. Vaginal administration of estradiol: effects of dose, preparation and timing on plasma estradiol levels. 

. 2015;18(2):121-134. doi:10.3109/13697137.2014.947254

20.Edwards L. Patient information packet. Mid-Charlotte Dermatology and Research Southeast Vulvar Clinic. Accessed July 11, 2022. https://nebula.wsimg.com/70af598099d980b624b0e104369f19c6?AccessKeyId=B78439C8610A1092E451&disposition=0&alloworigin=1

Correct terms and education can help normalize the conversation for patients.


Essentials of vulvovaginal dermatology

On April 26, 2022, the FDA approved inhibitor that targets CYP51 and is available as oteseconazole (Vivjoa), an oral azole antifungal indicated to reduce the incidence of recurrent vulvovaginal candidiasis (RVVC) in women with a history of RVVC who are not of reproductive potential.1 Oteseconazole is an azole metalloenzyme a single-drug regimen or in combination with fluconazole. Antifungal therapy may be instituted before the results of the cultures are known and adjusted accordingly when results become available.2

The first 2 clinical trials (NCT03562156 and NCT03561701)3,4 included a total of 656 adults and postmenarcheal pediatric women with RVVC who were randomly assigned to receive either oteseconazole only or placebo.

A third trial (NCT03840616)5 evaluated safety of oteseconazole vs fluconazole and placebo in 219 adults and postmenarcheal pediatric women with RVVC.2

Trials 1 and 2 each included an open-label induction phase and an 11-week maintenance phase. During the induction phase, participants received 3 sequential doses of fluconazole 150 mg every 72 hours on days 1, 4, and 7. At 14 days following the first fluconazole dose, if the acute VVC episode was resolved, participants were randomly assigned 2:1 to receive either oteseconazole 150 mg or placebo for 7 days, followed by 11 weekly doses during the maintenance phase; 326 and 330 patients, respectively, entered this phase. Primary efficacy end points were the proportion of patients with greater than or equal to 1 culture-verified acute VVC episode during the maintenance phase through week 48.3 The average percentage of patients with an acute VVC episode was lower in the oteseconazole group vs the placebo group in both trials (6.7% vs 42.8% and 3.9% vs 39.4%, respectively).2

Trial 3 evaluated the efficacy and safety of oteseconazole vs fluconazole and placebo. This trial also included induction and maintenance phases. Participants received a total dose of oteseconazole 150 mg over 2 days (600 mg [4 × 150 mg] on day 1 and 450 mg [3 × 150 mg] on day 2) or 3 sequential doses of fluconazole 150 mg every 72 hours on days 1, 4, and 7. Patients returned 14 days after the first dose and moved to the maintenance phase if the acute VVC episode was resolved. During the maintenance phase, patients received oteseconazole 150 mg or placebo weekly for 11 weeks.5 The primary efficacy end point was the proportion of patients with greater than or equal to 1 culture-verified acute VVC during the maintenance phase or who failed to clear their infection during the induction phase. The average percentage of patients with greater than or equal to 1 culture was lower in the oteseconazole group vs the fluconazole and placebo group (10.3% vs 42.9%, respectively).2

The most frequently reported adverse events were headache (7.4%) and nausea (3.6%). One patient discontinued therapy because of allergic dermatitis. Because of the risk of embryo-fetal toxicity, oteseconazole is contraindicated in women of reproductive potential and in women who are pregnant or lactating. Medication administration in conjunction with a high-fat, high-calorie meal increased concentrations, but no significant differences were observed with a low- fat, low-calorie meal.2

The oteseconazole-only dosage regimen is initiated as a 600-mg capsule on day 1 and 450 mg on day 2, each as a single dose. The next dose is administered on day 14 as a 150-mg capsule once weekly for 11 weeks.

The fluconazole/oteseconazole dosage regimen is initiated with fluconazole 150 mg orally on days 1, 4, and 7, followed by oteseconazole 150 mg once daily for 7 days, starting on day 14 through day 20. After day 20, the next oteseconazole dose is administered on day 28 as a 150-mg capsule once weekly for 11 weeks. Oteseconazole must be taken with food.2

FDA approves Mycovia Pharmaceuticals’ VIVJOA (oteseconazole), the first and only FDA-approved medication for recurrent vulvovaginal candidiasis (chronic yeast infection). News release. Mycovia Pharmaceuticals; April 28, 2022. Accessed July 12, 2022. 

https://mycovia.com/wp-content/uploads/2022/04/FINAL-Press-Release_04.28.22.pdf

Vivjoa. Prescribing information. Mycovia Pharmaceuticals Inc; 2022. 

https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215888s000lbl.pdf

A study of oral oteseconazole for the treatment of patients with recurrent vaginal candidiasis (yeast infection)(VIOLET). ClinicalTrails.gov. Updated April 6, 2022. Accessed July 12, 2022. 

https://clinicaltrials.gov/ct2/show/NCT03562156

A study of oral oteseconazole (VT-1161) for the treatment of patients with recurrent vaginal candidiasis (yeast infection) (VIOLET). ClinicalTrials.gov. Updated December 20, 2021. Accessed July 12, 2022. 

https://clinicaltrials.gov/ct2/show/NCT03561701

Study of oral oteseconazole (VT-1161) for acute yeast infections in patients with recurrent yeast infections (ultraVIOLET). ClinicalTrials.gov. Updated February 4, 2022. Accessed July 12, 2022. 

https://clinicaltrials.gov/ct2/show/NCT03840616

Oteseconazole is a treatment option for those living with a previously unmet medical need.

Vivjoa approved for recurrent vulvovaginal candidiasis

 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

Myovant announced the US Food and Drug Administration (FDA) has approved relugolix combination tablets (Myfembree; Myovant Sciences and Pfizer) for the treatment of moderate-to-severe endometriosis-associated pain.

Previously, Myfembree was only approved for the management of uterine fibroid-related heavy menstrual bleeding in premenopausal women.

“This approval is an important milestone reflecting Pfizer and Myovant’s commitment to women’s health in areas of significant unmet need,” said James Rusnak, MD, PhD, senior vice president, chief development officer, Internal Medicine and Hospital, Global Product Development at Pfizer. “We look forward to making Myfembree available to women with endometriosis and broadening their options in managing this complex disorder.”

This decision by the FDA is supported by 

 from two phase 3 studies (SPIRIT 1 and SPIRIT 2) investigating the combination tablet for treatment of dysmenorrhea.

In both studies, 75% of women using the once-daily relugolix combination therapy experienced a significant reduction in dysmenorrhea, compared to 27% and 30% of women in the placebo groups at Week 24, respectively (both p < 0.0001). Relugolix combination therapy also significantly reduced non-menstrual pelvic pain in 59% and 66% of women, compared to 40% and 43% in the placebo groups (p <0.0001).

In SPIRIT 1 and 2, the relugolix combination therapy group also showed reductions in dyspareunia and opioid use compared to the placebo groups. Additionally, more women undergoing relugolix combination therapy were opioid free at Week 24 compared with placebo (86% and 82% vs 76% and 66%, respectively).

The most frequently reported adverse events by women in both the relugolix combination therapy and placebo groups included headaches, nasopharyngitis, and hot flashes.

"The data from the SPIRIT studies showed the clinical benefit that relugolix combination therapy can have on moderate to severe pain associated with endometriosis and how it can impact patients,” said Linda Giudice, MD, PhD, distinguished professor at the University of California, San Francisco (UCSF), and chair, SPIRIT Program Steering Committee. “This newly approved option for patients with pain from endometriosis offers the convenience of one pill taken once daily with a mean change in bone mineral density of <1% that did not appear to worsen at 12 months of treatment; however, monitoring is recommended.”

Myfembree is now available with a prescription to patients with moderate-to-severe pain associated with endometriosis.

1. Myovant Sciences and Pfizer Receive U.S. FDA Approval of MYFEMBREE, a Once-Daily Treatment for the Management of Moderate to Severe Pain Associated With Endometriosis. Myovant Sciences. August 5, 2022. Accessed August 5, 2022. https://investors.myovant.com/news-releases/news-release-details/myovant-sciences-and-pfizer-receive-us-fda-approval-myfembreer

Myovant Sciences and Pfizer announces the US Food and Drug Administration has approved Myfembree (relugolix combination tablets) for the once-daily treatment of moderate-to-severe endometriosis-associated pain. 