D1.366 - “Intense peri-vaginal itching as a lone symptom”: a unique presentation of Progesterone (Progestogen) hypersensitivity (PH)

Progesterone (Progestogen) hypersensitivity (PH) is an underdiagnosed condition due to its varied presentation and difficult to diagnose scenarios. It is poorly understood and has multiple underlying pathophysiological conditions and triggers. Here I present a unique case that was presented without any rash or dermatitis, but only with severe peri-vaginal itching, which delayed the diagnosis by four years.

Data of a 43 years female who presented with severe, intermittent peri-vaginal and perineal itching for the past 4 years, was collected over time. Workup for fungal, bacterial and viral infections was negative. A trial of anxiolytics considering a psychological basis did not help her. She had never used contraceptive pills or intrauterine devices. Her history included use of condoms as barrier contraception. A skin prick testing was performed which ruled out latex allergy. She was advised to use cotton pads only, thus eliminating the possibility of irritant/allergic contact dermatitis due to synthetic menstrual pads. Her physical examination was absolutely normal, with no evidence of systemic or local dermatitis. On her third follow up, a detailed probing revealed that her itching would become extremely intense about a week prior to her menstrual bleeding and would subside after her menses. With this history, diagnosis of “Endogenous progesterone hypersensitivity” was established. Skin prick and intradermal tests for PH were negative. Patient was started on oral GnRH receptor antagonist, Elagolix sodium, on which she is symptom free for the past 14 months.

PH can uncommonly present as isolated peri-vaginal itching without skin manifestations. In addition, this case highlights the importance of detailed history taking to elucidate the etiology of hypersensitivity. The cyclical nature of her symptoms was an important clue leading to the diagnosis.

PH can present rarely with only peri-vaginal itching without any rash or skin manifestations. Oral GnRH antagonist can be considered as an effective therapy, as an alternative to the standard injectable GnRH agonist.