Atrophic vaginitis

Atrophic vaginitis is the chronic and progressive inflammation of the vagina (and the lower urinary tract) due to the thinning and shrinking of the vaginal tissues and is often accompanied by vulvar and urinary pathologies.^[1][2] These symptoms are due to a lack of the reproductive hormone estrogen. About half of all postmenopausal women experience this.^[3] However, this condition can occur in other circumstances that result in decreased estrogen such as breastfeeding and the use of medications.^[2] It has been proposed that the terms vulvovaginal atrophy and atrophic vaginitis be discontinued and replaced by genitourinary syndrome of menopause.^[2] Atropic vaginitis has "a profound negative impact on the quality of life of postmenopausal women."^[1] Women report that it reduced "their enjoyment of sexual activity" and decreased their general enjoyment of life.^[2]

Terminology

Vulvovaginal atrophy and atrophic vaginitis have been the preferred terms for this condition and cluster of symptoms until recently. These terms are now regarded as inaccurate in describing changes to the entire genitourinary system occurring after menopause. The term atrophic vaginitis suggests that the vaginal is inflamed or infected. Though this may be true, inflammation and infection are not the major components of postmenopausal changes to the vagina. The former terms do not describe the negative effects on the lower urinary tract which can be the most troubling symptoms of menopause for women.^[1] Genitourinary syndrome of menopause (GSM) was determined to be more accurate than vulvovaginal atrophy by two professional societies.^[2][4][5] The term atrophic vaginitis does not reflect the related changes of the labia, clitoris, vestibule, urethra and bladder.^[4]

Signs and symptoms

After menopause the vaginal epithelium changes and becomes a few layers thick.^[6] Many of the signs and symptoms that accompany menopause occur in atropic vaginitis.^[7] Genitourinary symptoms include

• dryness^[1][4]
• pain^[1][4]
• itching^[1][2]
• burning^[1][4]
• soreness
• pressure
• white discharge
• malodorous discharge due to infection
• painful sexual intercourse
• bleeding after intercourse^[8]
• painful urination^[1]
• blood in the urine
• increased urinary frequency^[1][4]
• incontinence
• increased susceptibility to infections^[1]
• decreased vaginal lubrication^[4]
• urinary tract infections^[2][4]
• painful urination^[4]
• difficulty sitting^[2]
• difficulty wiping^[2]

Incidence and causes

Up to 50% of postmenopausal women have at least some degree of vaginal atrophy. It is likely to be underdiagnosed and undertreated.^[2]

Diagnosis

Since women can have signs and symptoms that could be attributed to other causes, diagnosis is based upon the symptoms that cannot be better accounted for by another diagnosis.^[4] Lab tests usually do not provide information that will aid in diagnosing. A visual exam is useful. The observations of the following may indicate lower estrogen levels: little pubic hair, loss of the labial fat pad, thinning and resorption of the labia minora, and the narrowing of the vaginal opening. An internal exam will reveal the presence of low vaginal muscle tone, the lining of the vagina appears smooth, shiny, pale with loss of folds. The cervical fornices may have disappeared and the cervix can appear flush with the top of the vagina. Inflammation is apparent when the vaginal lining bleeds easily and appears swollen.^[2] The vaginal pH will be measured at 4.5 and higher.^[9]

Treatment

Symptoms of GSM will unlikely be resolved without treatment.^[2] Women may have many or a few symptoms so treatment is provided that best suits each woman. If other health problems are also present, these can be taken into account when determining the best course of treatment. For those who have symptoms related to sexual activities, a lubricant may be sufficient.^[2][10] If both urinary and genital symptoms exist, local, low-dose estrogen therapy can be effective. Those women who are survivors of hormone-sensitive cancer may need to be treated more cautiously.^[2] Some women can have symptoms that are widespread and may be at risk for osteoporosis. Estrogen and adjuvants may be best.^[10]

Topical treatment with estrogen is effective when the symptoms are severe and relieves the disruption in pH to restore the microbiome of the vagina.When symptoms include those related to the urinary system, systematic treatment can be used. Recommendations for the use of the lowest effective dose for the shortest duration help to prevent adverse endometrial effects.^[10]

Some treatments have been developed more recently. These include selective estrogen receptor modulators, vaginal dehydroepiandrosterone, and laser therapy. Other treatments are available without a prescription such as vaginal lubricants and moisturizers. Vaginal dilators may be helpful. Since GSM may also cause urinary problems related to pelvic floor dysfunction, a woman may benefit from pelvic floor strengthening exercises. Women and their partners have reported that estrogen therapy resulted in less painful sex, more satisfaction with sex, and an improvement in their sex life.^[2]

Research

The FDA has approved the use of lasers in the treatment of many disorders. The treatment of GSM is not specifically mentioned in the list of disorders by the United States' Food and Drug Administration but laser treatments have had success. Larger studies are still needed. The laser treatment works by resurfacing the vaginal epithelium and activating growth factors that increases blood flow, deposition of collage and the thickness of the vaginal lining. Women treated with laser therapy reported diminished symptoms of dryness, burning, itching, pain during sexual intercourse (dyspareunia), and painful urination (dysuria). Few adverse effects were noted.^[2]

References