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Silent postmenopausal problems: urogenital atrophy

Most women after the menopause develop a degree of urogenital atrophy due to lack of the main female hormone oestrogen. This can lead to some extremely distressing symptoms, yet many, mainly older women, keep these problems hidden from their partners, family and friends, and from the medical profession. Why are these common problems silent and hidden?

Dr Annie Evans
MB BChir MA FFFP
Woman's Health Specialist
Bristol Royal Infirmary and Nuffield Hospitals

The term urogenital atrophy means nothing to most women. Even specialists in women's health express themselves poorly, so how are women supposed to understand? Changes in the vagina, bladder and pelvic floor are not just issues for the women who live with the problems on a day-to-day basis - they are issues that should be actively managed by their healthcare providers.

Changes in the urogenital tract due to loss of oestrogen
These changes, due to the loss of oestrogen, affect the skin, collagen and support tissues of the vagina, bladder, urethra and pelvic floor. Usually in the sequence of postmenopausal events, they occur in the midterm - after the flushing and mood change, and before the long-term sequelae such as osteoporosis. For most women this means an onset about five years after the menopause. About 50% of postmenopausal women experience symptoms, and probably only a quarter of these women actually seek medical advice.(1,2)
The main urinary symptoms attributable to oestrogen lack are frequency, urgency, nocturia, mild urge incontinence and recurrent urinary tract infections (UTIs) (see Box 1).

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Vaginal changes include dryness, burning, itching, altered vaginal disharge, prolapse of the vaginal walls and, as a consequence, dyspareunia. The appearance of the vulva also changes and the vulva can become sore (see Box 2).

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A study in Holland of 2,000 women between the ages of 50 and 75 found 27% had vaginal symptoms and 36% urinary symptoms, and that women were more likely to be symptomatic following hysterectomy.(3)
Loss of oestrogen affects collagen production and metabolism in the lower genital tract. Both stress incontinence and prolapse are linked to a decrease in vaginal and periurethral collagen. Also the rectal muscle fascia becomes less elastic and easier to damage, and some women develop a degree of faecal incontinence.

Urinary incontinence
Urinary incontinence increases with age affecting 45% of the total female population, but 55% of 80-90-year-olds (again with a higher rate in those women who have had hysterectomy) and approximately 65% of elderly women in nursing homes.(4,5)
Oestrogen's effects on the bladder appear to be directly on the detrusor muscle, reducing the amplitude and frequency of its spontaneous, rhythmic contractions. In the urethra it helps to increase the closing pressure of the sphincter and therefore aids continence. However, most studies suggest that in the management of genuine stress incontinence, only a subjective improvement is obtained by using oestrogen, and oestrogen on its own is not an effective treatment.

Irritable bladder
In the management of irritable bladder problems, however, studies of vaginal oestrogens show very good results. Local oestrogen produces maturation of the vaginal epithelium at only 14 days, and a significant decrease in urinary urgency at six months.(6) Oestrogen has been shown to help with urge incontinence, frequency and nocturia, with vaginal oestrogen performing better than oral hormone replacement therapy (HRT) for symptoms of urgency.(7)

Vaginal atrophy (atrophic vaginosis)
Although dryness is often the first and best known symptom associated with vaginal atrohpy many other problems occur. Thinning of the vaginal epithelium leads to trauma and susceptibility to infection. Loss of oestrogen leads to reduced glycogen levels, which in turn leads to reduced lactic acid production by lactobacillus and increased vaginal pH. This leads to an alteration of the microbes in the vaginal secretions, producing aerobic vaginosis. The symptoms experienced by women are pruritus, discharge and dyspareunia.
Vaginal oestrogen not only improves the cytology of the vaginal mucosal cells, but also decreases the vaginal pH with a favourable effect on vaginal micro-organisms and a restoration of normal vaginal secretions (see Box 3).(8)

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Urogenital atrophy in other situations
Oestrogen depletion can occur at other female life stages or due to other conditions and medical treatments (see Box 4):

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Postpartum and lactation
The sudden drop in oestrogen levels after delivery may cause transient symptoms, adding to the effects of the trauma of delivery. Certainly lactation, if continued for weeks or months, causes urogenital atrophy in an unknown, but presumably large percentage of women. It is poorly recognised and very rarely treated.

Amenorrhoea (absence of periods) in young women
Whether primary, for instance due to genetic abnormalities, or secondary, as occurs with excessive exercise or anorexia, this again can cause symptoms and signs in the urogenital tract.

Effects of contraceptive hormones
The combined oral contraceptive pill, if predominantly progestogenic in content, may have a small effect on vaginal epithelium, discharge and vaginal flora.(9)  Injectable progestogens (DMPA) can induce hypo-oestrogenisation, with altered vaginal secretions, possible compromise of the vaginal barrier to infection and effects on the peristalsis and vasculature of the urinary tract, which can promote UTIs.(10)

Women with diabetes
In women with diabetes oestrogen therapy may be as important as antibiotics for the prevention of both UTI and bacterial vaginal infections.(11)

Treatment for endometriosis
Gondatropin-releasing hormone (GnRH) analogues, commonly used to treat endometriosis, may induce an iatrogenic menopause. Treatment with local vaginal oestrogen produces relief from the symptoms of urogenital atrophy with great effect in this group of women.(12)

Women on or after chemo- or radiotherapy
The problem of dyspareunia is of particular relevance in this group, and women who have had treatment for an oestrogen-dependant cancer are particularly vulnerable. More research is needed in this area, especially in relation to long-term safety of various treatment options (such as low-dose, local vaginal oestrogen).(13,14)

Early menopause
Women who have gone through menopause early, whether idiopathic, treatment-induced or surgical, often experience severe urogenital problems, as they start to develop earlier in life than after a natural menopause.

Hiding the problem
Most women find it hard to admit these problems even to their closest friends and few have the courage to ask their doctor or nurse for help. When women do talk, they feel it should not be happening to them and believe that they are suffering alone. Women are unaware how common their problems are, that there may be solutions available and are confused by the medical terminology. It is important that, as health professionals, we look at these issues from a woman's perspective.

What does a woman understand by vaginal atrophy?
Vaginal dryness is often the first problem that she will notice, but there may also be vaginal soreness, burning or itching, or changes in the appearance of the vulva, which she doesn't exactly know how to describe. She may experience thinning of the vaginal skin, causing it to be damaged easily. Lubrication may be poor and even gentle friction can cause pain.
Sex can become painful and may cause bleeding; this can be very frightening. Not surprisingly, women may completely lose interest in sex or are so embarrassed that they cannot risk intimacy when it is still needed and desired.
They may develop sore, thin vulval lips, which cause rubbing and chafing on underwear on a daily basis. The appearance of the vulva can change causing women to ask questions such as "Do I look normal down there?" In some women, the clitoral hood may retract leading to over-exposure of the clitoris, causing grief, trauma and discomfort. These problems lead many women to hide their bodies from husbands or partners. 
The change in the normal vaginal secretions is a grossly underestimated problem. Some women develop a vaginitis that can be mistaken for a sexually transmitted infection. The alkaline discharge caused by the rising pH can be sore and smelly. It does not lubricate, it is discoloured and it leads to burning and irritation.
This may cause gross embarrassment and fear about what is actually happening. Women confronted by this problem often try to solve it themselves, eg, they may buy an antifungal treatment from the local pharmacy. This can often aggravate the condition rather than improve it.
Some women experience a ballooning or bulging of the vaginal walls and the descent of the cervix. Others feel a generalised dragging sensation which causes gross discomfort on a daily basis.
There is also an awareness of a "latch-key" kind of incontinence where there is difficulty holding on when the bladder is full. There may be dribbling, leaking, going too often or the persistent feeling of needing to go to the toilet. Many women have to frequently visit the toilet in the night, causing severe sleep disturbance. To be able to do sport and go to the gym, many women start wearing sanitary pads again or inserting tampons to help support the pelvic floor and prevent leakage of urine. All these problems are difficult for women to live with, but they don't know who to talk to about them.

Are women just padding up and putting up? 
All women who have gone through the menopause need to be able to feel that they can talk about these very private concerns and problems with their friends, family and most importantly, with their doctors or nurses. As healthcare professionals we should encourage women not be worried about using nonmedical terminology to describe what is going on, and we should be able to explain the problems and possible solutions clearly and in simple language.

Treatment options
This is another situation where HRT can be considered if the woman is not already on it, as loss of oestrogen from the urogenital tissues is the main culprit. However, the risks and benefits of systemic HRT must be fully explored and, importantly, 10-25% of women already using systemic HRT will still show signs and have symptoms of urogenital atrophy.
Use of gentle, natural, plant-derived local oestrogen is an extremely good treatment, especially for vaginal atrophy, but it can also help with recurrent UTIs and bladder problems. It is available not only as creams and a ring, but also as vaginal tablets. The tablets are tiny and are inserted nightly into the vagina for two weeks, and then twice weekly for three months. This produces considerable improvement, but things may relapse again several months after stopping the course. The dose involved is only 10-30% of the oral dose and systemic absorption is very low, even once the first two weeks of treatment are over and the epithelium has matured again. Most experts feel this treatment is probably safe in longer courses.
Sometimes help is available from specialist nurse practitioners or pelvic floor physiotherapists.
There is also plenty available for self-help, eg, pelvic floor trainers, such as weighted vaginal cones to help with strengthening the pelvic floor muscles. Modern vaginal lubricants are also massively improved; some are so effective that they are available on prescription, but many are available to buy over the counter and pharmacists are always there to advise and help.

Conclusion
Healthcare professionals and all those in contact with postmenopausal women, or other situations where urogenital atrophy may arise, should learn to become more proactive in addressing these issues. Clear explanation of the causes and possible management options and treatments available addresses women's fears and can dramatically alter their quality of life. We need to be more open about these sensitive and silent problems.

References

  1. Online survey results 2005. Available from http://www.menopausematters.co.uk
  2. Robinson D, et al. Estrogen therapy in the treatment of urogenital atrophy. Clin Geriatr 2000;8:87.
  3. Van Geelen, Van de Weiger. Urogenital symptoms and resulting discomfort in non-institutionalized Dutch women aged 50-75 year. Int Urogynecol J Pelvic Floor Dysfunct 2000;11;9-14.
  4. Melville, et al. Healthcare discussions and treatment for urinary incontinence in US women. Am J Obstet  Gynecol 2006;194:729-37.
  5. Dubeau CE, et al. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc 2006;54:1325-33.
  6. Nilsson K, Heimer G. Low-dose oestradiol in the treatment of urogenital oestrogen deficiency - a pharmacokinetic and pharmacodynamic study. Maturitas 1992;15:121-7.
  7. Cardozo L, et al. A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand  2004;3:892-7.
  8. Galhardo CL, et al. Estrogen effects on the vaginal pH, flora and cytology in late postmenopause after a long period without hormone therapy. Clin Exp Obstet Gynecol 2006;33:85-9.
  9. Eschenbach DA, et al. Effects of oral contraceptive pill use on vaginal flora and vaginal epithelium. Contraception 2000;62:107-12.
  10. Ziaei S, et al. Urinary tract infection in the users of depot-medroxyprogesterone acetate. Acta Obstet Gynecol Scand 2004;83:909-11.
  11. Donders GG. Lower genital tract infections in diabetic women. Curr Infect Dis Rep 2002;4:536-9.
  12. Moghissi KS, et al. Goserelin acetate (Zoladex) with or without hormone replacement therapy for the treatment of endometriosis. Fertil Steril 1998;69;1056-62.
  13. Krychman ML, et al. Chemotherapy-induced dyspareunia: a case study of vaginal mucositis and pegylated liposomal doxorubicin injection in advanced stage ovarian carcinoma. Gynecol Oncol 2004;93:561-3.
  14. Ponzone R, et al. Vaginal oestrogen therapy after breast cancer: is it safe? Eur J Cancer 2005;41:2673-81.


Resources

Menopause Matters
W: www.menopausematters.co.uk

Women's Health Concern
W: www.womens-health-concern.org

The Daisy Network
W: www.daisynetwork.org.uk

British Menopause Society
W: www.thebms.org.uk

Novo Nordisk - Menopause Info
W: www.menopause-info.co.uk