Vaginitis, Atrophic Thuong-Thuong Nguyen MD Basics Description Vaginal epithelium thinning secondary to estrogen deficiency, resulting in vaginal dryness

s and inflammation Age-Related Factors Atrophic vaginitis is most common in menopausal and postmenopausal omen! May also "e present postpartum in a oman ho is "reastfeeding #pidemiology $%&'%( of postmenopausal omen have symptoms of atrophic vaginitis! Ris) Factors Menopause, either natural or surgical *oophorectomy+, Decline in endogenous estrogen -remenopause,
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.varian failure, /pontaneous or secondary to radiation or hemotherapy Antiestrogenic medications, Tamo0ifen, dana1ol, leuprolide, medro0yprogesterone -ostpartum loss of placental estrogen 2actation, -rolactin, antiestrogenic effects 3mmunologic disorder /mo)ing No vaginal delivery

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-athophysiology 4irculating estrogen, mainly estradiol, helps maintain vaginal epithelium elasticity and moistness "y stimulating the production of collagen and hyaluronic acid, respectively! #strogen stimulates non)eratini1ed stratified s5uamous epithelium to thic)en, form rugae, and fill ith glycogen,
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6lycogen from sloughed cells are converted into lactic acid "y D7derlein8s lacto"acilli, creating an acidic environment *p9 :!;&;+ that is protective against urogenital infections!

/ignificant reduction in circulating estrogen after menopause results in,

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Thin and less elastic vaginal epithelium, more suscepti"le to trauma and irritation /hortened and less rugated vaginal canal

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<;%( less vaginal secretions 3ncreased p9 and predisposition to infection "y /taphylococcus, /treptococcus, coliforms, and diphtheroids

Associated 4onditions The genital and urinary tract share a common em"ryologic origin! The urethral epithelium, "ladder, pelvic muscle floor, and pelvic fascia are also estrogen dependent! Dysuria, hematuria, urinary fre5uency may occur! Diagnosis /igns and /ymptoms The ma=ority of omen ith mild to moderate vaginal atrophy are asymptomatic! /ymptoms of atrophic vaginitis generally appear only after estrogen levels have "een lo for an e0tended period!

#arly on, omen may notice a slight decrease in vaginal lu"rication upon arousal, hich is one of the $st signs of estrogen insufficiency! 6enital symptoms, 3tching, dryness, "urning, dyspareunia, yello malodorous vaginal discharge, leu)orrhea, pruritus, pressure sensation >rinary symptoms, Dysuria, hematuresis, urinary fre5uency, >T3, stress incontinence Menstrual history 2ast menstrual period or final menstrual period /ymptoms of menopause, 9ot flashes, age of mother8s menopause ."stetric history, num"er of vaginal deliveries, num"er of ee)s postpartum, lactation *"reast-feeding or pumping? fully "reastfeeding or supplementing+ /e0ual history, Dyspareunia, se0ually active, use of lu"ricants, /T3s Medications, chemotherapy, radiation -M9, 3mmunologic disorder /mo)ing #0ogenous agents that may cause or further aggravate symptoms,
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9istory

-erfumes, po ders, soaps, deodorants, panty liners, spermicides, and lu"ricants may contain irritant compounds! 3n addition, tight-fitting clothing and long-term use of perineal pads or synthetic materials

Revie of /ystems /pecial attention to 6> symptoms -hysical #0am

6eneral, #0ternal genitalia, 2oss of la"ial and vulvar fullness, sparsity of pu"ic hair, dryness of la"ia, vulvar lesions, vulvar dermatoses, o Areas of microtrauma or fissures at peri-introital area and posterior fourchette may "e seen at colposcopy, if indicated
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/igns suggesting lichen sclerosus,

Fusion of la"ia minora ith ma=ora *loss of architecture+ 3ntroital stenosis

/igns suggesting vulvar vesti"ulitis,

Areas of focal erythema in hymenal sulcus

>rethral,
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>rethral caruncle, signifying eversion of urethral mucosa >rethral polyps #cchymoses

Vaginal,
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-allor of urethral and vaginal epithelium, decreased vaginal moisture /mooth or shiny vaginal epithelium? superficial epithelium may "e lost entirely 2oss of elasticity or turgor of s)in and vaginal epithelium /hortening and narro ing of the vaginal canal, ith loss of distensi"ility 2ac) of@flattening of rugae #asily traumati1ed epithelium ith areas of traumatic su"epithelial or epithelial hemorrhage or petechiae -elvic organ prolapse Rectocele 4ystocele

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Tests 2a"

/erum hormone levels are generally not helpful to assess for menopause, as F/9 can a0 and ane during menopausal transition! A lo level of circulating estradiol may "e present, "ut is not clinically useful *AB; pg@m2+! -ap smear can confirm the presence of urogenital atrophy!

Maturation inde0, 4ytologic e0amination of smears from the upper $@: of the vagina sho an increased proportion of para"asal cells and a decreased percentage of superficial cells!

An elevated p9 level *postmenopausal p9 levels C;+, monitored "y a p9 strip in the middle :rd of the vaginal vault, may also "e a sign of vaginal atrophy! Microscopy, .n microscopic evaluation, loss of superficial cells is o"vious ith atrophy, "ut there may also "e evidence of infection ith Trichomonas, 4andida, or "acterial vaginitis!

3maging TV>/ of the uterine lining that demonstrates a thin endometrium measuring "et een ' and ; mm signifies loss of ade5uate estrogenic stimulation! Differential Diagnosis 3nfection 4andidiasis Bacterial vaginosis

Trichomoniasis

Meta"olic@#ndocrine -.F *ovarian insufficiency+ -!B%: 3mmunologic 4ontact irritation or reaction to perfumes, po ders, deodorants, panty liners, perineal pads, soaps, spermicides, lu"ricants, tight-fitting or synthetic clothing .ther@Miscellaneous Vulvar lichen sclerosus Vulvar vesti"ulitis Treatment 6eneral Measures Moisturi1ers and lu"ricants may "e used in con=unction ith estrogen therapy or as alternative treatment, o Domen ho choose not to ta)e 9RT, have medical contraindications, or e0perience hormonal side effects!
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Daily moisturi1er, Replens, a long acting polycar"ophil-"ased, "ioadhesive polymer, produces a moist film over the vagina,

Relieves vaginal dryness, normali1es p9

Dater-"ased lu"ricants ith intercourse, Astroglide, E-F personal lu"ricant

/e0ual activity is a healthful prescription for postmenopausal omen,

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Vaginal intercourse encourages vaginal elasticity and plia"ility, and the lu"ricative response to se0ual stimulation!

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Fe er symptoms and less evidence of vaginal stenosis and shrin)age 4oital activity, including mastur"ation, associated ith fe er symptoms

/pecial Therapy 4omplementary and Alternative Therapies 3nsufficient evidence to support the use of D9#A-containing vaginal creams Medication *Drugs+ #strogen replacement, o Restores normal p9 levels? thic)ens and revasculari1es the epithelium
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3ncreases the num"er of superficial cells May alleviate e0isting symptoms or even prevent development of urogenital symptoms if initiated at the time of menopause! 4ontraindications to estrogen therapy include,

#strogen-sensitive tumors #nd-stage liver failure -ast history of venous throm"oem"olism

Adverse effects of estrogen therapy include,

Breast tenderness Vaginal "leeding and a slight increase in the ris) of an estrogen-dependent neoplasm Venous throm"oem"olism 3ncreased ris) of endometrial carcinoma and hyperplasia conclusively related to unopposed, estrogen inta)e

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Routes of administration include oral, transdermal, and intravaginal! Dose fre5uency may "e continuous, cyclic, or as-needed for symptomatic relief! The amount and duration re5uired to eliminate symptoms depends on the degree of vaginal atrophy!

/ystemic administration of estrogen has "een sho n to have a therapeutic effect on symptoms of atrophic vaginitis! Additional advantages include a decrease in postmenopausal "one loss and alleviation of hot flashes!
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/tandard dosages of systemic estrogen, ho ever, may not eliminate the symptoms of atrophic vaginitis in $%&B;( of patients! /ystemic estrogen in higher dosages may "e necessary to alleviate vaginal symptoms!

/ome omen re5uire coadministration of a vaginal estrogen product applied locally!

2o -dose local estrogen preferred,

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4reams, pessaries, ta"lets, rings similarly effective in treatment of symptoms, /ymptom relief ith little endometrial proliferation Vaginal rings, #string or -hadia, #stradiol impregnated silastic ring is inserted into the vagina and delivers G&H Ig of estradiol daily for : months! Favored most for comfort and ease of use! 4reams, con=ugated estrogens *-remarin+, Daily for : ee)s, then t ice ee)ly for $B ee)s Ta"let, Vagifem, B; Ig estradiol t ice a ee) 9igher-dose local estrogen treats atrophic vaginitis, hot flushes, and "one loss!

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Vaginal ring, Femring, Releases ;%&$%% Ig@d? replaced in : months!

Follo up Disposition 3ssues for Referral >rogynecology for urinary symptoms or pelvic organ prolapse -rognosis Most omen get relief of symptoms ith vaginal formulations of estrogen! /ystemic estrogens may re5uire the addition of vaginal estrogen formulations!

Nonestrogen therapies are less effective for most omen than estrogen!

-atient Monitoring Assess compliance *fre5uency of use+ and need for progestin therapy in omen on estrogen therapy, TV>/ may "e helpful in assessing endometrial proliferation! Bi"liography Bachmann 6A, et al! Diagnosis and treatment of atrophic vaginitis! Am Fam -hys! B%%%?G$,:%H%! Ballagh /A! Vaginal hormone therapy for urogenital and menopausal symptoms! /emin Reprod Med! B%%;?B:*B+,$BG&$'%! Botsis D, et al! Transvaginal sonography in postmenopausal omen treated ith lo dose estrogens locally administered! Maturitas! $HHG?B:,'$&';! 4ardo1o 2, et al! Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal omen, /econd report of the 9ormones and >rogenital Therapy 4ommittee! ."stet 6ynecol!$HHJ?HB,KBB! 4astelo-Branco 4, et al! Management of post-menopausal vaginal atrophy and atrophic vaginitis! Maturitas! B%%;?;B*/uppl $+,/'G! 2ei"lum /, et al! Vaginal atrophy in the postmenopausal oman, The importance of se0ual activity and hormones! LAMA! $HJ:?B'H,B$H;!

Nyir=esy -! Vaginitis! Dashington, D4, American 4ollege of ."stetrics and 6ynecologists! -ractice Bulletin, Num"er KB? May B%%G! -andit 2, et al! -ostmenopausal vaginal atrophy and atrophic vaginitis! Am L Med /ci! $HHK?:$',BBJ! /anten RL, et al! Treatment of urogenital atrophy ith lo -dose estradiol, -reliminary results! Menopause! B%%B?H,$KH! /uc)ling L, et al! 2ocal oestrogen for vaginal atrophy in postmenopausal omen! 4ochrane Data"ase /yst Rev! B%%:?4D%%$;%%! Dillhite 2A, et al! >rogenital atrophy, -revention and treatment! -harmacotherapy! B%%$?B$,'G'! Miscellaneous /ynonym*s+ M >rogenital atrophy M /enile vaginitis 4linical -earls M Domen ho are "reastfeeding may "e una are of the possi"ility of atrophic vaginitis and can "enefit from education and therapy! M K;&J%( of omen ith atrophic vaginitis do not inform their health care provider of their symptoms "ecause they "elieve these are part of aging! A""reviations M D9#ANDehydroepiandrosterone M F/9NFollicle-stimulating hormone M 9RTN9ormone replacement therapy M -M9N-ostmenopausal hormone M -.FN-remature ovarian failure M TV>/NTransvaginal ultrasound 4odes 34DH-4M GBK!' -ostmenopausal or senile vaginitis -atient Teaching A4.6 -atient #ducation -amphlet, Vaginitis -revention M Regular se0ual activity including mastur"ation is associated ith fe er symptoms of atrophic vaginitis, even ithout therapy! M 3nitiation of estrogen therapy at time of menopause may alleviate and prevent symptoms of atrophic vaginitis!