Atrophic vaginitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2] Aravind Kuchkuntla, M.B.B.S[3]

Synonyms and Keywords: Atrophic vulvovaginitis; vaginal atrophy; urogenital atrophy; genitourinary syndrome of menopause

Overview

Atrophic vaginitis is defined as inflammation of the vaginal epithelium due to atrophy secondary to decreased levels of circulating estrogen. The features of this disease are estimated to be seen in 15% of premenopausal and 50% menopausal women. Patients present with the symptoms of vaginal dryness, itching, irritation, and dyspareunia. Diagnosis of atrophic vaginitis requires subjective assessment of the severity of symptoms to be correlated with the physical examination findings. The prominent physical examination findings include atrophic vaginal or vulvar tissue, pale, smooth and shiny vaginal epithelium with increased friability and inflammation with patchy erythema. The characteristic findings to confirm the diagnosis are: a left shift of the vaginal maturation index on a vaginal smear and a alkaline pH of the vagina. However, other secondary causes such as lichen sclerosus and lichen planus must be ruled before the confirmation of the diagnosis. The therapeutic management is based on the severity of the symptoms: lubricants are the first line of therapy for mild symptoms, in patients unresponsive to lubricants and with moderate to severe symptoms topical or oral estrogen therapy is effective for the management of patients . Majority of the patients have resolution of symptoms but due to the chronic nature of the condition it requires continuous treatment.

Historical Perspective

  • In 1898, Charles B. Penrose described vaginitis in elderly women as senile Vaginitis. The areas of patchy inflammation were treated with 5% silver nitrate solution.[1]
  • In 1940, Jacob described the use of vaginal pH in determination of hypoestrogenic state.[2]
  • In 1947, Racoff gave a description the efficacy and safety of a synthetic estrogen, dienestrol for the treatment of menopausal syndrome and atrophic vaginitis is described.[3]
  • In 1963, topical Dinesterol vaginal cream was used for the treatment of senile vaginitis.[4]
  • In 1967, the relationship between the vaginal maturation index and estrogen therapy was described.[5]
  • In 2013, vulvovaginal atrophy is renamed as genitourinary syndrome of menopause.[6]

Classification

Atrophic vaginitis is classified based on the symptom severity into:[7]

  • Mild: Patients present with symptoms related to sexual activity.
  • Moderate to severe: Patients with persistent symptoms not related to sexual activity.

Pathophysiology

Pathogenesis

The pathogenesis of atrophic vaginitis is due to decreased estrogen levels. Estrogen is a vasoactive hormone, which increases blood flow and maintains vaginal lubrication through fluid transudation from blood vessels.[8] The following are the manifestations of decreased estrogen levels:[8][9][10]

Genetics

There are no genetic factors associated with atrophic vaginitis.

Gross Pathology

Gross pathology findings in atrophic vaginitis include:[11]

  • Vaginal dryness
  • Loss of vaginal rugae
  • Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa

Microscopic Pathology

  • Cytology of the vaginal cells show an increase in the parabasal cells and decreased superficial cells. In situations of low estrogen levels the vaginal epithelium ceases to produce superficial and intermediate squamous cells, leaving only the parabasal and basal cells lining the vaginal wall.[12]

Associated Conditions

Causes

Atrophic vaginitis is caused by any condition that may lead to decreased circulating estrogen levels. A hypoestrogenic state may be due to ovarian failure or other causes:[8]

Ovarian Failure Other causes
Menopause Elevated Prolactin during the Postpartum period
Premature Ovarian Failure

Bilateral oophorectomy

Pituitary Adenoma
Chemotherapy and Radiation Medications with anti-estrogenic effect

Epidemiology and Demographics

  • Atrophic vaginitis is often an underdiagnosed condition and exact prevalence estimation is difficult because of the following reasons:
    • Majority of women are embarrassed to discuss their symptoms with doctors and few others think the symptoms associated with atrophic vaginitis as a process of natural aging.[14]
    • Only 25% of patients with symptoms seek medical care.[15]
    • Inadequate relief of symptoms with treatment.[16]
  • The features of atrophic vaginitis are estimated to be seen in 15% of premenopausal women and 40-54% of post-menopausal women.[17]
  • Based on self-reported symptoms of vaginal dryness, the prevalence of atrophic vaginitis ranged from 4% to 47%, depending on the stage of menopause (early or late menopause).[9]

Risk Factors

The risk factors associated with vaginal atrophy are related to decreased estrogen levels, which can be due to menopause (most common cause) or other causes that may lead to hypoestrogenism or vaginal atrophy. These include:[8]

Screening

There are no screening recommendations for atrophic vaginitis.[18]

Differentiating atrophic vaginitis from other diseases

Atrophic vaginitis must be differentiated from other disease processes that may present with similar symptoms. These can be divided into 4 categories:[9] [8]

The conditions which may need to be differentiated from the atrophic vagintis and presents as vulvar or vaginal pruritus, dryness, discharge and dyspareunia include the following: [19][20][21][22][23]

Disease Findings
Atrophic vaginitis
Trichomoniasis
Bacterial Vaginosis
Candida Vulvovaginitis
Lichen Sclerosus
Lichen Planus
  • Affects pre-menopausal and post menopausal women[25]
  • T-cell mediated inflammatory disease affecting mucosal membranes
  • In erosive form patients present with vulvar pain, dyspareunia and dysuria
  • Non-erosive form presents with pruritus
  • On examination, lesions appear as red plaques or erosions, with overlying white violaceous or reticular plaques( Wickham Striae)
  • Diagnosis confirmed by shave or punch biopsy
Lichen simplex chronicus
  • On examination, the lesion appear as thick, erythematous lichenified skin (epidermal thickening and accentuation of skin markings)
  • Due to long-term rubbing or scratching secondary to conditions such as recurrent yeast infections, contact dermatitis, psychiatric illness[26]
Contact dermatitis
  • It could be allergic or irritant contact dermatitis
  • Presents with redness, swelling, and pruritus[27]
  • Ocassionally blistering and painful bright red swelling can be seen
Vulvar intraepithelial neoplasm
  • Bimodal peak is observed between 40-44 years and above 55 years[28]
  • Red, white, or dark raised or eroded multifocal lesions [29][30]
Vulvar Cancer
Extramammary Paget disease

Natural History, Complications and Prognosis

Natural History

Atrophic vaginitis is a chronic progressive medical problem affecting postmenopausal women and in younger women with low estrogen levels. Women present with vaginal dryness, pruritus, urinary disturbances and dyspareunia.[34]

Prognosis

Atrophic vagnitis is a chronic disease and requires continuous treatment with estrogen or other alternatives. Majority of the patients have significant resolution of the symptoms with treatment, however the symptoms recur once the treatment is stopped.[35]

Complications

Complications of atrophic vaginitis include:[8][36][17]

Diagnosis

History and Symptoms

Symptoms of atrophic vaginitis can be divided into three categories:[8][9][10]

Physical Examination

Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, a speculum examination.[10][21]

Laboratory Findings

Assessment of Vaginal Atrophy

  • Vaginal Cytology: It demonstrates a decrease in the superficial squamous cells and an increased parabasal cells.[12]
  • Vaginal Maturation Index(VMI): It represents the percentage of the parabasal, intermediate and superficial squamous cells. It read from left to right as follows, for example if its represented as 0/35/65-it means the smear has 0% parabasal cells, 35% intermediate cells and 65% superficial cells. A shift to the left indicates vaginal atrophy.[38]
  • Vaginal Maturation Value (VMV): It is calculated using a formula: 0 * %parabasal cells + 0.5 * %intermediate cells + 1.0 * superficial cells divided by 2.
    • A lower VMV indicates a low number of superficial cells indicating hypoestrogenic state.[39]
  • Vaginal pH : Normal vaginal pH is acidic and is maintained by the lactobacillus flora by the breakdown of glucose (from the vaginal epithelial cell glycogen-the level of which is based on the estrogen) to lactic acid.
    • In lower estrogen states, the vaginal pH is typically greater then 5; higher than normal due to lower levels of glycogen in the epithelial cells. It is a useful and inexpensive test in the absence of bacterial vaginosis to indicate vaginal atrophy.[40]
  • Wet mount of vaginal smear : Demonstrates the paucity of lactobacillus.
  • FSH Level: Estimation of FSH is not neccessary for the diagnosis of hypoestrogenic state as alkaline pH of vaginal secretions is equally sensitive.[41]

Ultrasound

An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.[8]

Treatment

Medical Therapy

Atrophic vaginitis is a chronic condition requiring continuous treatment. The choice of therapy is based on the severity of the symptoms and associated factors such as history of hormone dependent cancer. [42][43]

Treatment Modality Improvement in symptoms Advantages Limitations
Topical Estrogen[46][9][47]

(Creams and Estradiol releasing vaginal rings)

  • No systemic absorption
  • 80 to 90% patients have symptomatic improvement[50]
  • Creams can be messy to use
  • Rings are expelled in patients with cystocele and rectocele
  • Side effects include vaginal secretion, vaginal spotting, and genital pruritus
Oral Estrogen Therapy

In addition to the changes with topical estrogen other actions include:

Selective estrogen receptor modulator

Ospemifene[51]

Laser Therapy
  • Improvement of symptoms sustained at 12 weeks after therapy
  • Improved sexual activity[55]
Lack of long term evidence on efficacy and safety[56]
  • Common adverse effect is hot flashes
  • Contraindicated in patients with DVT
Tibolone

Synthetic steriod

  • Improves VMI, sexual desire with the androgenic activity[57]
  • Improvement in urinary symptoms
  • Lack of long term evidence on efficacy
  • Increases recurrence risk of breast cancer in patients with history of breast cancer
  • Vaginal spotting and bleeding[59]
Oxytocin
  • Oxytocin gel improves vaginal secretions and epithelial thickness and pH[60][61]
  • No long term evidence[62]
Intravaginal dehydroepiandrosterone
  • Improves vaginal epithelium thickness and secretions[63][64]
  • None
  • Lacks long term studies
Moisturizers and lubricants[65]
  • Polymers adhere to the epithelial and mucin improving vaginal lubrication
  • Temporary relief for patients with mild symptoms
  • No effect on reversal of atrophic changes

Assessment of Response to treatment

  • Atrophic vaginitis being a chronic disease, continuous therapy is recommended. Response to treatment is assessed by the following:[8]
    • Vaginal Maturation Index(VMI) assessment
    • Vaginal pH assessment

Prevention

Primary Prevention

There are no primary preventive measures for atrophic vaginitis.

Secondary Prevention

The following behavioral changes are advised to slow down the progression of atrophic vaginitis, and also help in maintenance of normal vaginal tissue:[66]

  • Encouraging sexual activity helps in the maintenance of vaginal elasticity and lubrication in response to sexual stimulation.
  • Stress reduction therapy is helpful in patients with non-organic causes of vaginal dryness.
  • Cessation of smoking
  • Encourage the use of looser undergarments; it increases the vascularity and prevents infections.

References

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