Continuing Education Activity

Vaginal atrophy is thinning of the vaginal epithelium and decreased cervical secretions most closely related to changes in estrogen levels. It is a common but often missed condition, especially in those who are post-menopausal. To avoid many of the health and lifestyle complications, it must be asked, diagnosed, and treated promptly. This activity reviews the evaluation and treatment of vaginal atrophy and highlights the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Identify the etiology and epidemiology of vaginal atrophy.
• Identify the common history and physical presentation of vaginal atrophy.
• Outline the different treatment modalities of vaginal atrophy.
• Discuss interprofessional team strategies for improving care coordination and communication to advance care and improve outcomes for vaginal atrophy.

Introduction

Vaginal atrophy is now included under the new term genitourinary syndrome of menopause (GSM), which also includes vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis. We will focus on vaginal atrophy. It is most commonly due to decreased estrogen levels in postmenopausal women or women of any age who experience a decrease in estrogenic stimulation of the urogenital tissues. Vaginal atrophy signs and symptoms present similar to many other genitourinary conditions, thus delaying diagnosis and management.[1] It also changes the anatomy and physiology of the genitourinary system. Treatment requires proper diagnosis, nonhormonal therapy, and hormonal interventions.

Etiology

Estrogen stimulation is responsible for maintaining the normal anatomy and physiology of the urogenital system. There are receptors in the vagina, vulva, urethra, and trigone of the bladder that respond to estrogen stimulation to maintain normal blood flow, tissue thickness, tissue rugate, tissue elasticity, and keeps the epithelial surfaces moist. This healthy tissue is rich in glycogen, which the normal flora Lactobacilli convert to lactic acid. This creates an acidic environment with a pH of 3.5 to 5.0, which the lactobacilli continue to thrive and protect from vaginal and urinary tract infections.

Concurrently, sexual activities promote epithelial turnover and elevated vaginal lubrication. Vaginal atrophy is most commonly caused by a decreasing or lower estrogen state. As production and amount of total body estrogen decreases, secretions diminish, and the genitourinary tissues become atrophic, causing the many symptoms associated with this condition. Other causes of vaginal atrophy include lactation, hypothalamic amenorrhea, and anti-estrogen medications such as those used to treat uterine fibroids and endometriosis.[1][2][1]

Epidemiology

Vaginal atrophy can be a common issue for all women. However, it shows much more prevalence among the postmenopausal population. Reports show that 15% of the female population experiences symptoms of vaginal atrophy before menopause, whereas 40% to 57% of postmenopausal women have symptoms. Menopause causes a dramatic 95% reduction in estrogen production.

Approximately 70% of women with signs and symptoms do not discuss the issue with their provider.[3] Women are often reluctant or embarrassed to discuss or receive treatment for their symptoms. They believe they are expected and part of the aging process. One must also take into account cultural, religious, and societal beliefs. Most are even not aware of treatment modalities. Thus, less than 25% do not receive care, and providers do not screen for symptoms of vaginal atrophy. This not only results in underdiagnosing but also undertreatment of this condition.

Although most typically seen in postmenopausal women, there are additional risk factors that can contribute to decreased estrogen levels and early symptom onset. These are women who have bilateral oophorectomy, primary ovarian insufficiency, ovarian failure due to radiation or arterial embolization, hypothalamic-pituitary disorders, take anti-estrogen medications such as leuprolide or danazol used commonly for endometriosis, and postpartum breastfeeding mothers. Also at risk are breast cancer survivors suffering from consequences from treatment such as chemotherapy or aromatase inhibitors.[1][4][5]

Pathophysiology

Vaginal atrophy occurs in conditions causing a diminished estrogen state. Estrogen typically stimulates exfoliation of vaginal epithelial cells, causing increased levels of glycogen in which vaginal flora lactobacilli convert into lactic acid. This process allows for the replacement of older vaginal epithelium, keeping the typical acidic pH of the vaginal canal. As estrogen levels decrease, this process is hindered, and the vaginal epithelium becomes atrophic with diminished secretions and a less acidic environment (pH >5).[6][5] This, in turn, increases the risk of vaginal and urinary tract infections.

History and Physical

Many of the presenting symptoms of vaginal atrophy may easily be attributed to other genitourinary conditions such as vaginal infections or urinary tract infections. It may be difficult for a clinician to diagnose vaginal atrophy if a complete history is not obtained, including a sexual history. Ask about sexual habits and activities. This will rule out many other causes, especially genitourinary infections. As these symptoms onset, many patients find sexual activity difficult due to the changes in the vaginal mucosa and may avoid it altogether, further contributing to the atrophy.[5][6][7] Dwell into obstetric and gynecologic history and interventions, menstrual history, medications now and in the past, and use of any potential irritants in the area. It is vital that the proper questions be addressed to screen for this condition, as it may not be diagnosed otherwise. This includes asking patients of specific symptoms described below, as some patients may not be entirely forthcoming without the clinicians' help.

Patients suffer from vaginal atrophy experience symptoms, including vaginal dryness, burning, irritation, dyspareunia, post-coital bleeding, vaginal bleeding, and dysuria. A decrease in vaginal lubrication during sexual activities is often first to follow by just daily activities. In addition, as vaginal pH alters, so does the vaginal flora. With these new conditions, women are at increase risk for recurrent vaginal infections and urinary tract infections. Recurrent symptoms of genitourinary infections should raise concern to the clinician for possible vaginal atrophy as a predisposing factor.

Note the anatomical changes of the vaginal area: scarce pubic resorption or fusion of labia major or minor, introital retraction, urethral, and surrounding area eversion or prolapse. Note and evaluate the changes during the speculum exam: tissue fragility, rugae, elasticity, amount of lubrication or secretions, and/or shortened, narrowed, and poorly distensible vaginal vault. Look for pallor, erythema, fissure, petechiae. Be cautious during pelvic and speculum exams, as it may cause pain and bleeding.

A pale, dry, smooth, shiny, and inflammation changes such as patchy erythema or petechiae or increased visibility of blood vessels are all classical findings of atrophy. There may also be friability, bleeding, and discharge.[8]

Evaluation

Laboratory tests such as urinalysis and culture, urine antigen for sexually transmitted infections, and pelvic cultures are usually used to rule out genitourinary infections. Measurement of estrogen in the form of serum estradiol is inaccurate, and current assays are not sufficiently sensitive to detect accurately.[9] Vaginal pH measurement is useful if >5 in the absence of any infections or discharges. Currently, research is the Maturation Index Test. The lining cells of the vaginal wall are measured with atrophy demonstrating shifting and loss of superficial cells to basal cells.

Treatment / Management

Vaginal atrophy has a few different treatment modalities. It can be classified into non-hormonal and hormonal options.

Non-hormonal treatment with vaginal/topical moisturizers and lubricants is considered first-line. Lubricants provide short-term relief for patients and are typically used for vaginal dryness during intercourse, while moisturizers have a longer-lasting effect and may be used daily to every 2-3 days per week.  Patients are also encouraged to continue safe, regular sexual activity. The use of moisturizers, lubricants, and regular safe sexual activities helps in maintaining the health and integrity of the vaginal epithelium and flora.

As the environment of the vagina is altered with the progression of vaginal atrophy, the pH and osmolality of the moisturizer/lubricant are also of importance. The clinician should be prescribing topical vaginal moisturizers and lubricants which are closest to the physiological conditions of the natural vaginal environment. This not only assists in symptomatic relief of the patient but may also decrease the incidence of promoting vaginal infections. 

Hormonal therapy would be an additional or second-line treatment as it focuses on treating the root cause of the symptoms. Moisturizers and lubricants are still considered the first line, but if symptoms persist, hormonal therapy may be necessary. Hormonal replacement therapy (HRT) may be systemic (oral estrogen replacement) or localized (intravaginal/topical estrogen, estrogen intravaginal releasing ring, and vaginal dehydroepiandrosterone (DHEA, testosterone). Studies show that systemic HRT alleviates symptoms in 75% of cases, whereas local therapy does so in 80%-90% of cases. Side effects are comparable but local therapy is considered much safer than systemic.

Local estrogen therapy comes in many forms including vaginal creams which are typically applied daily, intravaginal tablets/capsules for more accurate dosing of estrogen, and a vaginal ring which releases small amounts of estrogen daily. Local estrogen therapy should be initiated at lower doses. All preparations were all similarly effective in alleviating vaginal atrophy symptoms. Low dose local estrogen therapy has not been shown to increase total systemic estrogen levels, and overall have an excellent safety profile showing a minimal to no increased risk of endometrial hyperplasia in healthy females.[10][5]

Women usually have an improvement in symptoms after 2 to 4 weeks of treatment, which can indicate continue response at 12 weeks.[11] The lowest dose can be used indefinitely with monitoring of risks and benefits although no studies have women followed beyond one year.

As with all medication regimens, risk and benefits should be discussed with patients prior to initiating any hormonal therapy. At increased risk are breast cancer or endometrial cancer survivors, as their tissues may be more sensitive to lower levels of estrogen which may increase their risk for new or recurrence of cancer. Vaginal/topical estrogen therapy may still be used in these patients, but the risk of hormone sensitivity should be discussed, and if initiated should be done so at lower doses.

Systemic hormonal replacement therapy is typically reserved for patients experiencing systemic menopausal symptoms (ie night sweats, hot flashes, and flushes) in addition to vaginal atrophy. In patients who do suffer from these symptoms, systemic HRT's, including estrogen-progestins, or simply estrogen in females who have had a hysterectomy, have shown to have significant results. Females using systemic HRT's had growth and revascularization of the vaginal epithelium, normalized vaginal pH, and increased lubrication.

An additional treatment, especially useful for patients with a history of hormone-sensitive cancer, are selective estrogen receptor modulators (SERM). SERMs are able to have a positive effect on the vaginal epithelium while having minimal to no effect on estrogen-dependent organs. More recent treatment modalities include laser and radiofrequency therapy. Laser therapy is able to promote re-vascularization and restores vaginal moisture and elasticity, however, the safety and efficacy are uncertain.[12][13][14][15]

If there are anatomical vulvovaginal changes, vaginal dilators may be of use. This is reserved for women who cannot take estrogen therapy and failed moisturizers and lubricants. Dilators have shown to improve vaginal function.[16]

Differential Diagnosis

Associated symptoms and signs of vaginal atrophy overlap with many other vaginal conditions, making it more difficult for a clinician to contribute the symptoms solely to atrophy. Differential diagnoses must exclude the presence of vulvovaginitis, including candidiasis, bacterial vaginosis, trichomoniasis. Sexually transmitted infections, such as gonorrhea and chlamydia. Dermatologic conditions including lichen planus, lichen sclerosis, or inflammation secondary to an irritant. Symptoms and signs may also mimic urinary tract infections or malignancy.[2]

Although these differential diagnoses must be ruled out, their presence does not exclude the diagnosis, and simply may be recurring symptoms/infections secondary to ongoing vaginal atrophy.

Prognosis

Women suffering from vaginal atrophy are able to get significant symptomatic relief with treatment if diagnosed and discussed. Women who do not undergo management will, unfortunately, continue to experience ongoing symptoms, which can increase frustration, poor sexual lifestyle, recurrent infections, and overall lead to a decreased quality of life.

Complications

If not asked, identified, and treated early, vaginal atrophy will cause recurrent genitourinary infections and much vaginal/pelvic discomfort and pain.

Deterrence and Patient Education

The symptoms of vaginal atrophy can be vague and non-specific. In addition, many women do not disclose their symptoms to their clinician. Patients should not only be screened for symptoms during an evaluation but should be educated on what symptoms to watch for, especially in the postmenopausal population. This allows patients to be vigilant and more open to presenting these symptoms to their clinicians when they arise.

Enhancing Healthcare Team Outcomes

Vaginal atrophy is a condition affecting the pre and postmenopausal populations. Often its symptoms are contributed to other conditions or not relayed to the clinician at all. Healthcare providers have the ability to significantly improve identification, management, and quality of life in all of these patients. It is imperative that clinicians ask the questions needed to screen for this process and to encourage patients to relay these symptoms if they occur. If patients are reluctant to inform their caregivers of these symptoms, they will continue to suffer from decreased quality of life and ongoing symptoms detrimental to their genitourinary health. It is the responsibility of the healthcare team to assist in identifying and treating vaginal atrophy prior to any of these complications. [Level V]