Atrophic Vaginitis

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Atrophic Vaginitis

• Mohamed Kandeel
• M.B.B.Ch., M.Sc.(Ob/Gyn), M.D.(Ob/Gyn)
• Professor of Obstetrics and Gynecology
• Menofyia University
• Egypt

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Definition 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.

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Etiology

• 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

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Diagnosis

• 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.

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Diagnosis (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

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Diagnosis (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

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Diagnosis (Cont.)

• -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

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Diagnosis (Cont.)

• 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 lt25 pg/mL
• 3-Microscopy (wet mount) to rule out vaginitis
  due to bacterial vaginosis, candidiasis, and
  trichomoniasis

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Diagnosis (Cont.)

• 4-Cytology
• In a postmenopausal woman, due to lack of
  estrogen, a vaginal smear shows lack of
  maturation of vaginal cells (superficial cells lt
  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.

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Complications

• Bacterial or fungal vaginal infections
• Cracks in the vaginal wall.
• Dyspareunia and bleeding after intercourse

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Treatment

• 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.

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Treatment (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.

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Treatment (Cont.)

• 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.

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Treatment (Cont.)

• 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 23 times per week for
  long-term maintenance.
• 2 Vagifem vaginal inserts One insert is used
  in the vagina each night for 714 nights, and
  then reduced to one insert two nights per week
  for maintenance.

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Treatment (Cont.)

• 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.

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Treatment (Cont.)

• 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.

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Treatment (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.

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Treatment (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

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Side 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.

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Contraindications of local estrogen

• Unexplained vaginal bleeding
• Pregnancy
• Estrogen-sensitive tumors,
• End-stage liver failure and
• Past history of estrogen-related
  thromboembolization.

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Prognosis

• The condition usually responds to proper
  treatment. In resistant cases, the uterus should
  be curetted to exclude endometrial carcinoma or
  associated senile endometritis.

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Thank You