Atrophic vaginitis

Atrophic VaginitisAtrophic Vaginitis

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Definition and IncidenceDefinition and Incidence

• Atrophic vaginitis, sometimes called vaginal atrophy, is a chronic

progressive condition occurs mainly in postmenopausal women and is

characterized by pale, thin, shining, shrunken and atrophic vaginal

epithelium. In addition to vagina, the atrophic changes also affects the

urinary tract because of their common embryologic origin.

• The condition develops slowly and it takes 5-10 years after menopause to

manifest. Atrophic vaginitis affects 50-60% of postmenopausal women; of

them only 25% seek medical advice. It may occur in women at

childbearing period after delivery or with breastfeeding.


EtiologyEtiology

1-Menpopause: due to lack of estrogen. Dramatic decline in the circulating

estrogen levels occurs at menopause from 120 pg/ml to 18 pg/ml

2-Pelvic irradiation or chemotherapy

3-Oophorectomy

4-Anti-estrogns: e.g. Tamoxifen, Danazol, Medroxyprogesterone, GnRh

agonists

5-Immediately after delivery or breast feeding

6-Anorexic women & women who have recently lost a significant body

weight

6-idiopathic


DiagnosisDiagnosis

• A combined approach is mandatory to reach a correct diagnosis of atrophic

vaginitis. This approach consists of; 1) proper history taking with special

emphasis on any contact irritant such as local perfumes or deodorants or

lubricants, 2) physical examination and 3) laboratory testings.

• Be careful to avoid the routine diagnosis of atrophic vaginitis in

postmenopausal women with urogenital complaints.

• Exclude other causes of vaginal infection such as bacterial vaginosis,

candidiasis or trichomoniasis.


DiagnosisDiagnosis (Cont.) (Cont.)

I-History: of

-Frequency of urine, dysuria, nocturia, hematuria and incontinence.

-Malodorous thick yellowish discharge.

-Dyspareunia which may be followed by bleeding after intercourse.

-Vaginal soreness and itching


Diagnosis Diagnosis (Cont.)(Cont.)

II-Physical examination:

Vaginal examination should be performed using a small lubricated

speculum to 1) avoid injury or bleeding from the atrophic vaginal tissues

2) minimize discomfort to the patient.

Examination reveals:

1- Stenotic introitus: width is less then 2 fingers

2- Decreased vaginal depth.

3- Pale dry vagina with friable epithelium which lacks normal mucosal rugae



-Diminished or absent elasticity of vagina.

-Minimal vaginal lubrication due to decreased vaginal blood flow.

-Petechiae may be present on the vaginal lining.

-Vulvar tissue may appear diminished, obliterated, or even fused.

-Clitoral shrinkage



III- Laboratory testing:

1-PH:

Vaginal pH in atrophic vaginitis is more than 5 measured with pH indicator

strip inserted into the proximal one-third of the vagina

2-Low level of circulating estrogen <25 pg/mL

3-Microscopy (wet mount): to rule out vaginitis due to bacterial vaginosis,

candidiasis, and trichomoniasis



4-Cytology:

• In a postmenopausal woman, due to lack of estrogen, a vaginal smear shows

lack of maturation of vaginal cells (superficial cells < 30%) with

predominance of intermediate, parabasal and metaplastic cells. These cells

are characterized by the high nuclear cytoplasmic ratio, round nucleus, and

basophilic cytoplasm. They are uniform in size and shape. Parabasal cells

also may contain cytoplasmic vacuoles and are known as foam cells.

• In premenopausal & younger woman, vaginal cells are mature. i.e

superficial. The superficial cells are large cells with either a small round

pyknotic nucleus or lack a nucleus if they are cornified. Cytoplasm is

abundant and keratinized. Cell margins are angular with folded edges. They

are a rich source of glycogen for the lactobacilli.


ComplicationsComplications

• Bacterial or fungal vaginal infections

• Cracks in the vaginal wall.

• Dyspareunia and bleeding after intercourse


TreatmentTreatment

I- Prophylaxis:

Post-menopausal women should be advised to continue regular

sexual activity. Sexual activity improves blood circulation in the

vagina, which helps maintain the tissue.

Younger women who had their ovaries surgically removed or

irradiated should start hormone replacement therapy.


TreatmentTreatment (Cont.) (Cont.)

II- Curative:

1-Nonhormonal:

• First-line therapy for women with vaginal atrophy includes non-hormonal

water soluble vaginal lubricants and moisturizers. Women should also be

encouraged to continue sexual activity.



2-Hormonal:

• Bio-identical vaginal preparations are more effective than oral or

transdermal preparations in releifing manifestations of atrophic vaginitis.

• Bio-identical vaginal estrogen require lower doses than systemic therapy;

and it is the treatment of choice for such women

• Bio-identical vaginal estrogen therapy is available in many forms (creams,

tablets, suppositories or rings). The best selection is the form that best suits

an individual patient.



• Examples of bio-identical local vaginal estrogens::

1- Estriol vaginal cream: One gram is applied to the vagina nightly for 7-

10 nights then the dosage is reduced to 2–3 times per week for long-

term maintenance.

2 Vagifem vaginal inserts: One insert is used in the vagina each night for

7–14 nights, and then reduced to one insert two nights per week for

maintenance.



3- Estrace vaginal cream: 1 gram is applied to the vagina nightly for 7 -

10 nights, then reduced to 1-3 times per week for long-term

maintenance

4- Estring 90-day vaginal ring: 1 ring is inserted into the vagina and

remains there for 90 days when it is removed & replaced with new

ring.

• Premarin Vaginal Cream which is commonly prescribed by many

gynecologists is not a bio-identical estrogen. Biodentical local estrogen are

either equal or superior to, premarine.



• local bio-identical estrogens are always preferred to systemic

estrogenic preparations. They improve atrophic vaginitis with

minimal systemic absorption.

• Systemic estrogen administration in standard doses does not necessarily

improves symptoms of atrophic vaginitis; however, higher doses improves

manifestations of atrophic vaginitis in a large proportion of women (close

to 85%). In addition, it has the advantage of decreasing postmenopausal

bone loss and control of vasomotor dysfunction.


Treatment Treatment (Cont.)(Cont.)

• Vaginal preparations improves symptoms and signs in 80% of women

within 3 weeks of commencing therapy.

• Long term treatment with vaginal estrogenic may improve bone density

and lower total cholesterol level, low density lipoprotein and

apolipoprotein. Such preparations are unlikely to have adverse effects on

long term use.

• Treatment should be continued till improvement occurs. Either continuous

regimen or intermittent approach can be employed.


Treatment Treatment (Cont.)(Cont.)

• Follow-up visits should include assessment of symptoms, vaginal

morphology, and pH.

• Patients at high risk for endometrial cancer, & those using a higher E dose

or having vaginal spotting or breakthrough bleeding may require closer

surveillance.

• Women with hormone-dependent cancer are not ideal candidates for

treatment with local E, but such women with severe symptoms not

improved with conservative measures may be considered for E therapy


Side effects of local estrogen therapySide effects of local estrogen therapy

1-Breast discomfort

2-Vaginal bleeding Both 1 and 2 are the commonest side effects

3-Endometrial proliferation

4-A slight increase in the risk of an estrogen-dependent neoplasm.


Contraindications of local estrogenContraindications of local estrogen

• Unexplained vaginal bleeding

• Pregnancy

• Estrogen-sensitive tumors,

• End-stage liver failure and

• Past history of estrogen-related thromboembolization.


PrognosisPrognosis

• The condition usually responds to proper treatment. In resistant cases, the

uterus should be curetted to exclude endometrial carcinoma or associated

senile endometritis.


Atrophic vaginitis

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