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Vaginal Atrophy: The 21st Century Health Issue Affecting Quality of Life



Vaginal Atrophy: The 21st Century Health Issue Affecting Quality of Life
Vaginal dryness and atrophy is a silent epidemic that affects many women who are undoubtedly suffering in silence. This chronic and progressive medical condition has been estimated to affect up to 50%-60% of postmenopausal women[1]; some healthcare providers believe this estimate is lower than the actual incidence. With increased life expectancy, the impact of vaginal dryness on quality of life, sexual functioning, and urogynecologic health is becoming more evident in the day-to-day practice of medicine. Many younger women and those in perimenopause (or in the transitional period) may also experience periodic vaginal dryness and associated problems.
Women with this condition may have a variety of symptoms that may include vaginal and vulvar pain, external and internal irritation, and aches in the vulva and vagina. Vaginal dryness due to lowered estrogen levels or hypoestrogenemia can be accompanied by itching, severe burning, discharge, and dyspareunia (painful intercourse).[2] They may also develop an aversion or fear of pelvic and digital examinations.

After a very meticulous and comprehensive history, some women will discuss intimate sexual complaints, such as painful intercourse with diminished or loss of sex drive and problems with arousal or orgasm that are causing personal and marital distress. Dyspareunia secondary to vaginal atrophy is an important contributor to female sexual dysfunction.[3] Frequently, women also report urogenital problems and urinary complaints that may include multiple irritative urinary tract infections, dysuria, nocturia, increased urinary frequency and incontinence, and discomfort originating from the urethral opening.[4] Such urogenital changes, coupled with changes in sexual function, can significantly affect overall quality of life.

Women are reluctant to discuss their concerns with their healthcare providers for several reasons: embarrassment, cultural taboos, fear that there are no available treatments, and concern about clinician reactions to discussion of intimate symptoms. In turn, healthcare providers may also be reluctant to discuss these issues as well. Although there are also a variety of reasons for clinician reluctance, some of the most common include lack of expertise in sexual assessment and treatment approaches, time constraints, and uncertainty about treatment options.

Diagnosis

Vaginal atrophy can be diagnosed with a detailed history and comprehensive physical examination. On physical examination, the vagina is dry, with pale, frail tissue, and lacking the normal mucosal ridges and folds. The expected elasticity and pliability associated with a well estrogenized vagina maybe absent. There is minimal lubrication due to decreased vaginal blood flow, and the tissues are easily traumatized with digital or pelvic examination. There may also petechiae or small hemorrhages on the vaginal lining. The vaginal introitus may be narrowed; the epithelial surface is typically very friable and may be ulcerated.[5] Vulvar tissue may appear diminished, obliterated, or even fused, and irritation and erythema evident. Pubic hair is often diminished and there can be clitoral tissue shrinkage; pelvic organ prolapse is not uncommon.

As an adjunct to the physical examination, vaginal pH can be easily measured. It is typically greater than 5.0 in patients with atrophic vaginitis.[6] Additional testing, including cytology and wet mount smears, can facilitate and substantiate diagnosis. Some sexual healthcare specialists are now using high-resolution vulvoscopy for further examination of vulvar tissue to exclude possible underlying pathology. A biopsy of any suspicious lesion should be performed and the sample sent for comprehensive pathologic assessment.

First-Line Treatment Options

Treatment goals for atrophic vaginitis include alleviating symptoms, reversing or minimizing the physiologic changes, and improving quality of life for the patient. Individualized care and treatment can most often be considered the rule. Symptoms, medical history, personal lifestyle, and treatment goals should all be taken into account when constructing the patient management schema and selecting a treatment agent.[7]

Nonhormonal treatments. A number of over-the-counter (OTC) vaginal moisturizer and lubricant products are considered first-line nonhormonal treatments for vaginal dryness. This option is most appropriate for women concerned about hormone use, those with minimal physiologic changes or symptoms, or those who are not candidates for estrogen treatment. However, definitive efficacy data are lacking for almost all of the OTC preparations used for treating atrophic vaginitis.

Vitamin E gel caps can be punctured and the gel placed in the vagina -- use of a panty liner is recommended because vitamin E is staining. Replens, a polycarbophil-based vaginal moisturizing gel, is typically placed in the vagina up to 3 times weekly. It acts as a bioadhesive and produces a moist film that adheres to the vaginal surface. Replens has been shown to restore vaginal pH and improve cytological morphology.[8,9]

A variety of water-based products are also available; all are compatible with barrier methods, including condoms and diaphragms. Silicone-based lubricants can also be used. These typically last longer than water-based products, will not soak into the skin, require less reapplication, and are tasteless and odorless. Silicone products do not promote stickiness or tackiness and have an added advantage that they can also be used as a sensual massage lotion.

Some women may also have a sensitivity or allergy to components of moisturizers or lubricants. OTC products may contain warming additives, dyes, perfume, bactericides, or spermicides that can further irritate already sensitive, dry vaginal mucosa. Other common vaginal and vulvar irritants include benzocaine, chlorhexidine, preservatives (parabens and propylene glycol), and condoms made of latex or containing lanolin. Petroleum-based products (eg, mineral oil and petroleum jelly) can interfere with condom efficacy and disturb the natural balance of vaginal flora, so these should be avoided.

Pharmacologic treatment. Local, low-dose estrogen preparations are considered first-line pharmacologic treatment for atrophic vaginitis. A recently published position statement from the North American Menopause Society (NAMS) provided evidence-based conclusions and made recommendations specific to the role of local estrogen preparations for treatment of vaginal atrophy in postmenopausal women. The complete document is available online.[7]

The statement was developed by selected experts in the field of urogenital disease who reviewed, synthesized, and interpreted current data from the scientific and medical literature; conclusions and recommendations were subsequently endorsed by the NAMS Board of Trustees. Findings include (1) data from the limited number of randomized, controlled clinical trials currently available demonstrate that low-dose vaginally applied estrogen products are effective and well tolerated, with low side effect profiles; (2) all of the low-dose vaginal estrogen products available in the United States are equally effective at the doses recommended in product labeling; and (3) progestogen use is generally not indicated when low-dose estrogen is administered locally for treatment of atrophic vaginitis.[7]

There are numerous local estrogen delivery products to choose from, including vaginal rings, creams, suppositories, and tablets. Although concerns differ with respect to delivery system, side effect profiles are similar. Vaginal bleeding, breast discomfort, nausea, endometrial proliferation and perineal pain have been reported with use of all products.[7] However, side effects may be more frequent with use of products providing higher estrogen doses than those with lower doses. A detailed review of atrophic vaginitis and estrogen treatment options is available online in a Medscape activity provided by Arias and Gorodeski.[10]

Patient preference is extremely important when selecting a treatment delivery method. Discussion of the pros and cons of each product and consideration of patient symptoms, lifestyle, and individual requirements facilitate an optimal choice and significantly contribute to treatment adherence. Some women prefer vaginally applied cream because it is soothing and can also be applied to the exterior vulva and clitoral region; others may have difficulty with insertion or find a cream product to be slightly "messy." The once every 3-month dosing schedule of the silastic vaginal ring is extremely convenient, but sensing the ring during sexual intercourse, associated excessive vaginal discharge, or expulsion during urination or defecation are potential drawbacks that should be considered. Vaginal tablets are convenient, less messy than cream preparations, and have a low side effect profile, but some patients may find it difficult to remember twice-weekly dosing.

Treatment length is variable, but should be continued as long as distressing symptoms that impaired quality of life are present.[7] Some patients may favor continuous treatment while others prefer an intermittent approach. Follow-up plans should include ongoing assessment of symptoms, vaginal morphology, and vaginal pH.

The NAMS position statement concluded that data supporting annual endometrial sampling or transvaginal ultrasound in patients without symptoms was inadequate.[7] However, a related conclusion is that patients at high risk for endometrial cancer, and those using a higher estrogen dose or experiencing vaginal spotting or breakthrough bleeding may require closer surveillance.