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Vaginal atrophy: treatment and advice

Charles Broomhead
MB ChB FRCGP DA DRCOG
GP and GP Trainer Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School
E:charles.broomhead@lineone.net

Vaginal atrophy (also sometimes known as atrophic or senile vaginitis) is most commonly associated with the menopause and is caused by the decline in oestrogen levels. This causes atrophy of the oestrogen-dependent vaginal epithelial cells and a simultaneous reduction in cervical mucus production. A reduction in vaginal lubrication is often the first symptom to be noticed, followed by other vaginal or urinary symptoms. Other causes of the condition include oophorectomy, radiotherapy, chemotherapy and some drugs (for example, medroxyprogesterone, danazol and nafarelin), that might be used to treat conditions such as infertility, fibroids or endometriosis. In the postpartum period, vaginal atrophy may be seen as a result of a dramatic and sudden fall in placental oestrogen levels, accompanied and exacerbated by increased prolactin levels during lactation.
Stimulation of the vaginal epithelium by oestrogen results in the production of large amounts of glycogen. Lactobacilli thrive within this environment, lowering vaginal pH to between 3.5 and 4.5, and providing protection against vaginal and urinary tract infections. The raised pH encountered after the menopause thus increases the likelihood of infection by a variety of organisms. Other effects of a drop in oestrogen levels include a decline in vaginal blood flow, decreased cellular collagen content, and a marked reduction in mucosal thickness. Urethral epithelium is also oestrogen-dependent, accounting for some of the urinary symptoms that are common in peri- and postmenopausal women.

Symptoms
Common symptoms of vaginal atrophy include vaginal dryness, itching or burning sensations, dysuria and dyspareunia. Even minor trauma, perhaps as a result of sexual intercourse, will sometimes cause bleeding, necessitating investigation in order to rule out a sinister cause.
While it is estimated that up to 40% of postmenopausal women experience symptoms related to oestrogen deficiency, studies reveal that as few as 20% seek treatment for the problem, which may not appear for 10 years or more after their last menstrual period. Occurring, as it does, at a time in their lives when many women feel vulnerable, unattractive and uncertain about the future, the condition can cause considerable emotional distress and may irreparably damage relationships. The intimate nature of the problem means that many women are reluctant to ask for help to deal with the problem and both doctors and nurses often fail to volunteer assistance. Interestingly, symptoms have been shown to be more severe in women who are smokers or who have not delivered vaginally.(1) They are less pronounced in those postmenopausal women who maintain a sexual relationship, although whether this is cause or effect may be difficult to establish.(2) Regular sexual activity either by masturbation or sexual intercourse is thought to improve vaginal blood flow and to maintain vaginal tissue.

Investigation
Physical examination is usually all that is required to confirm the diagnosis of atrophic vaginitis. Digital and speculum examination may be difficult and uncomfortable as a result of the narrowing of the introitus and should be performed gently. Inspection of the vulva and vagina usually reveals a thin, dry, pale, smooth epithelium that lacks the rugosity seen in younger women. Such examination is essential as it also helps to rule out other pathology such as candidiasis, genital malignancies, cystocoele or rectocoele. Serum hormone levels, measurement of the vaginal pH and cytology may provide further confirmatory evidence, but if any doubt remains, referral to secondary care will be necessary. This is especially recommended in the case of unexplained vaginal bleeding.

Treatment
Before instituting any form of therapy there should of course be a full assessment of the patient, including details of her previous medical history, current medication, family history, diet and lifestyle. Advice concerning the use of vaginal deodorants, perfumed soaps, underwear and the wearing of tights may be useful and always demands consideration. An essential part of this consultative process is to clearly identify what each particular patient's wishes are about her treatment. These vary widely and should not be determined by the views of either doctor or nurse.
As explained previously, oestrogen deficiency is the fundamental cause of age-related vaginal atrophy and, for the majority of women, supplementation of this hormone will bring a significant improvement in the condition. Its action is to encourage the proliferation of vaginal epithelium. Hormone replacement can be delivered orally, transdermally or by subcutaneous implant. In those women who still have a uterus,
coadministration of progesterone is essential to reduce the risks of endometrial hyperplasia and carcinoma. Treatment may be cyclical or continuous depending on the age and wishes of the individual woman.
Considerable concern has recently been expressed in relation to the possible long-term consequences of using hormone replacement therapy (HRT). The association between this, adverse cardiovascular events and an increased incidence of malignancies has led to the general recommendation that systemic replacement should be used only for the short-term relief of menopausal symptoms and after a full explanation of the risks of treatment.(3)
While systemic HRT offers the prospect of relieving concomitant symptoms such as hot flushes and night sweats, where these symptoms are absent or where patient preference dictates that it is inappropriate, oestrogen may be administered locally in the form of vaginal gels, tablets, creams, pessaries or rings. Conjugated equine oestrogen products are reported to be associated with a higher incidence of adverse side-effects such as breast or perineal pain and uterine bleeding than are those containing oestradiol. A review of the literature in 2003 demonstrated that while all of these forms of treatment are effective in relieving the symptoms of vaginal atrophy, many women prefer the oestradiol-containing vaginal ring for "ease of use, comfort of product and overall satisfaction".(4) Vaginal rings are relatively easy to insert and remove. They may either remain in place or be removed before intercourse depending on the wishes of the individual couple.
A further advantage of topical vaginal therapy may be that the oestrogen is delivered directly to the site of the symptoms and hepatic first-pass metabolism is avoided. This permits the use of lower doses than are required with oral therapy. Notwithstanding this, there are concerns that some vaginal creams produce plasma hormone concentrations that are significantly higher than those seen with oral preparations. Circulating oestrogen levels may thus be high enough to cause endometrial hyperplasia. Serum oestradiol levels do not appear to rise with use of the currently available vaginal tablets or ring, and this may be a good reason to recommend these delivery systems to patients who are considering the vaginal route of administration.
Thin atrophic vaginal mucosa allows the rapid absorption of relatively large amounts of hormone, but as recovery occurs there is a corresponding decrease in the amount detectable elsewhere within the body.
Vaginal oestrogen supplements are generally only advised for the short-term relief of symptoms related to vaginal atrophy in postmenopausal women. In those women who have an intact uterus, balancing progesterone treatment is not generally considered to be necessary.(5) Where therapy is for a longer period, the evidence for this is less substantial, and manufacturers generally advise a maximum duration of therapy, intermittent use or discontinuation and reassessment at frequent intervals.
Because of the low systemic absorption, vaginal oestrogen preparations are sometimes used to treat symptoms of vaginal atrophy in women who have a history of breast cancer.(6) This is a prescribing decision, however, that should be made only after taking specialist advice.
A water-soluble lubricant such as K-Y jelly (Johnson & Johnson) can of course be used during sexual intercourse, and for many women may be all that is necessary to relieve their symptoms. Acetic acid jelly (Aci-jel; Janssen-Cilag) may be effective where an increase in vaginal acidity is considered appropriate but oil-based lubricants such as petroleum jelly are generally best avoided. A more sophisticated approach is to use a product such as Replens MD (Anglian), a polycarbophil-based vaginal moisturiser. This is a bioadhesive polymer that is capable of holding up to 60 times its own weight in water and which acts by adhering to the vaginal epithelium. As well as providing lubrication, it also restores vaginal pH to within the physiologically normal range. One application every two to three days is generally effective, and for many women this is an attractive option, avoiding as it does the need to use a lubricant immediately before intercourse.

Complementary therapies
There appears to be some evidence that vitamin D and a soya-rich diet may be effective in treating vaginal atrophy.(7,8) Omega-7 and phytosoya vaginal gel, both available at pharmacies and health stores, are said to be effective in treating vaginal dryness, although scientific evidence for this is lacking. Some women claim to have found tea tree oil-based products helpful.

Conclusion
Vaginal atrophy is a common, often distressing condition that afflicts many women at the time of the menopause. Professional help and advice is often not sought due to embarrassment, but there are many things that can be done to improve the condition. While oestrogen replacement remains one of the most effective forms of treatment, there are other nonhormonal options that many women find effective.

References

  1. Kalogeraki A, et al. In Vivo 1996;10:597-600.
  2. Leiblum S, et al. JAMA 1983;249:2195-8.
  3. British Menopause Society. Consensus statement on HRT. Available at URL: http://www.the-bms.org/consensus.htm
  4. Suckling J, et al. Cochrane Database Syst Rev 2003;CD001500.
  5. Willhite LA, O'Connell MB. Pharmacotherapy 2001;21:464-80.
  6. Pritchard KI. Ann Oncol 2001;12:301-10.
  7. Yildirim B, Kaleli B, Duzcan E, Topuz O. Maturitas 2004;49:332-7.
  8. Chiechi LM, et al. Maturitas 2003;45:241-6.