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atrophic vaginitis

also see genitourinary syndrome of menopause Etiology: - estrogen deficiency - menopausal genitourinary syndrome - lichen sclerosus - some pharmaceutical agents may exacerbate vaginal dryness - aromatase inhibitors, tamoxifen - progestins - antimuscarinic agents - antihistamines Epidemiology: - most common cause of vaginal discharge & vaginal bleeding in post-menopausal women - 10-40% of postmenopausal women Pathology: 1) atrophy, thinning of the vaginal epithelium 2) shift in cell structure to parabasal cells a) high nuclear to cytoplasmic ratio 'blue blobs" b) cells do not produce much glycogen on which Lactobacillus depend 3) vaginal pH increases to > 4.5 because of decreased lactate production 4) fissures may form 5) decreased height of rugae 6) decreased vaginal secretions 7) shift in vaginal flora from Lactobacillus* to predominantly bowel-related bacteria (Streptococcus & Prevotella) [5] 8) vulvar atrophy * Lactobacillus is estrogen-dependent [5] Clinical manifestations: 1) vulvovaginal irritation & dryness - vulvovaginal itch - vaginal atrophy may lead to tears & trauma (fissures) to the labia - vulvar atrophy 2) dyspareunia 3) watery, yellow (serosanginous) discharge 4) vaginal wall generally appears thin & pale, but may be erythematous 5) vaginal bleeding may occur easily 6) urinary urgency 7) urinary frequency 8) dysuria 9) pelvic examination in [2] described as atrophic vaginitis &/or vaginal atrophy - pale vaginal mucosa with visible veins - mildly stenotic introitus - diminished vaginal caliber & length Laboratory: - wet mount - numerous leukocytes & basal epithelial cells Management: 1) hormone-free vaginal moisturizers/lubricants may control symptoms in some women - the North American Menopause Society recommends initiating nonhormonal therapies as first-line treatment, except if urinary symptoms [11] - see genitourinary syndrome of menopause 2) estradiol vaginal* - patients seem to prefer tablets or the vaginal ring over cream [2] - neither vaginal estrogen (tablet) or vaginal moisturizer better than lubricating gel [8] - women with urinary symptoms may benefit more from topical estrogen therapy [11] - women with dyspareunia respond to topical estrogen [2] 3) oral estrogens equally effective - include progestin if uterus is intact 4) if incontinence pads are used & vulvar irritation occurs, discontinue the incontinence pads rather than estrogen even if minimal improvement with estrogen [10] 5) high-potency topical glucocorticoid (clobetasol 0.05%) for lichen sclerosus 6) avoid pharmaceutical agents that may exacerbate vaginal dryness, if possible (see etiology) 7) CO2 laser treatment through vaginal probe every 6 weeks [7] 8) radiofrequency or energy-based laser devices have not been proven safe of effective for postmenopausal vaginal atrophy [9] * concurrent progestin not needed with low-dose vaginal estrogen since systemic absorption is insufficient to cause endometrial proliferation [1]

Related

menopausal genitourinary syndrome; genitourinary syndrome of menopause

General

vaginitis vaginal atrophy; vulvovaginal atrophy

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18. American College of Physicians, Philadelphia 1998, 2015, 2018.
  2. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; - Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Bachmann G, Bouchard C, Hoppe D et al Efficacy and safety of low-dose regimens of conjugated estrogens cream administered vaginally. Menopause. 2009 Jul-Aug;16(4):719-27 PMID: 19436223
  4. Lynch C. Vaginal estrogen therapy for the treatment of atrophic vaginitis. J Womens Health (Larchmt). 2009 Oct;18(10):1595-606 PMID: 19788364
  5. Brotman RM et al. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause 2014 May; 21:450 PMID: 24080849
  6. No authors listed Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013 Sep;20(9):888-902 PMID: 23985562
  7. Sokol ER, Karram MM. An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy. Menopause 2016 Oct; 23:1102 PMID: 27404032
  8. Mitchell CM, Reed SD, Diem S et al Efficacy of Vaginal Estradiol or Vaginal Moisturizer vs Placebo for Treating Postmenopausal Vulvovaginal Symptoms. A Randomized Clinical Trial. JAMA Intern Med. Published online March 19, 2018. PMID: 29554173 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2674257
  9. FDA Safety Communication. July 31, 2018 FDA Warns Against Use of Energy-Based Devices to Perform Vaginal 'Rejuvenation' or Vaginal Cosmetic Procedures: FDA Safety Communication. https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm615013.htm
  10. Lifits-Podorozhansky YM et al Role of vulvar care guidelines in the initial management of vulvar complaints. J Low Genit Tract Dis. 2012;16(2):88-91 PMID: 22227837
  11. North American Menopause Society The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017 Jul;24(7):728-753 PMID: 28650869 http://www.menopause.org/docs/default-source/2017/nams-2017-hormone-therapy-position-statement.pdf