vaginal health/quality of life
Another benefit of routine exams.
From Medscape Ob/Gyn & Women’s Health
Vaginal Atrophy: The 21st Century Health Issue Affecting Quality of Life
Posted 08/31/2007
Michael L. Krychman, MD
INTRODUCTION
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.[
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.Special Populations
Vaginal atrophy can also be associated with abruptly induced menopause and result in significant symptoms, sexual dysfunction and distress, and poor quality of life. Cancer treatments (surgically induced menopause, chemotherapy induced ovarian failure, radiation damage to ovaries, or maintenance endocrine therapies) can all cause ovarian dysfunction and lead to vaginal atrophy. For example, patients with breast cancer treated with an aromatase inhibitor have been found to experience significant vaginal dryness and painful coitus.[11]
Cancer
The NAM position statement also addresses women with past or current treatment for a malignancy in whom vaginal atrophy develops. Recommendations include that those without hormonally sensitive tumors should not be treated differently than routinely managed postmenopausal patients.
However, patients with hormonally sensitive carcinoma (common in breast and endometrial malignancies) require individualized treatment, based on extensive discussion between the patient and her oncological management team. The safety of local estrogen use in breast or endometrial cancer survivors or those with a strong family history of breast cancer has not been adequately studied in long-term, randomized, placebo-controlled trials. To date, no vaginal estrogen product has been approved by the Food and Drug Administration for use in patients with a hormonally sensitive malignancy.
Presently there is no established protocol for use of local estrogen in breast cancer survivors with vaginal atrophy. Of note, in a cohort study of almost 1500 previously treated patients with breast cancer, no statistically significant difference in disease free interval was found between a subgroup of women using vaginal estrogen and those not using estrogen.[12]
Several sexual medicine programs are investigating use of individually tailored treatment of vaginal atrophy to determine the lowest dose of local estrogen significantly associated with effective physiological results. Women with hormonally sensitive cancer, other malignancies, and women without cancer are participating in these investigations. Data from these studies have not been published.
Use of local estrogen in patients with endometrial cancer remains controversial; many clinicians opt for no estrogen therapy while others consider use permissible. Tumor stage, grade depth of invasion, and time since cancer treatment may factor into the decision process.
A related concern is that local estrogen could possibly effect endometrial proliferation, which in turn could increase the risk of endometrial cancer. However, a study of low dose vaginal ring and vaginal tablet users that assessed endometrial thickness via ultrasound found no significant changes in the endometrium.[13]
Additionally, Nachtigall reported results of use of low-dose estrogen therapy evaluated via endometrial biopsy that showed no significant local or first-pass absorption into the uterus.[14] Based on these data, she contended that treatment with low-dose estrogen is safe in early stage endometrial cancer survivors who have undergone hysterectomy and were appropriately staged and effectively treated.
Appropriate discussion concerning the lack of long-term safety data, coupled with meticulous, well-documented informed consent specific to risks and benefits should take place prior to prescribing local estrogen for any patient with a history of a hormone-sensitive malignancy.
Endometriosis or Leiomyomata (FIBROIDS)
Young women with endometriosis or large leiomyomata treated with gonadotropin-releasing hormone agonists or antagonists that induce a hypoestrogenic state may suffer from periodic vaginal atrophy and should be evaluated and treated accordingly. Use of minimally absorbed vaginal estrogen products is warranted because treatment has a positive effect on atrophy and does not reactivate underlying endometriosis.
Lactation
Women BREASTFEEDING exclusively may experience lactation-induced amenorrhea, diminished estradiol levels, and elevated prolactin and oxytocin levels. These changes can cause vaginal dryness and atrophy, accompanied by lowered libido and painful, unsatisfying intercourse. Because many healthcare providers attribute decreased sexual interest during the postpartum period to other causes (fatigue/sleeplessness, exhaustion of motherhood, changing sexual dynamics of the couple, stress and recovery from delivery), lactation-induced vaginal atrophy often is misdiagnosed or remains undiagnosed.
Other special causes of vaginal atrophy should always be considered, so that these women can be identified and effectively managed. Additional plausible causes of vaginal and vulvar atrophy include allergy suffers with chronic antihistamine use those being treated with parasympathomimetic or tricyclic antidepressant medications.[15] Women using an oral contraceptive may also experience dryness. Women with Sjorgen’s syndrome may experience lack of vaginal lubrication despite adequate estrogen levels. Atrophic vaginitis also can develop in anorexia nervosa, bulimia, or in those undergoing infertility treatments
Clinical Pearls
Vaginal atrophy is often neglected by the even the etude healthcare professional. Additionally, patients are frequently hesitant to discuss possibly embarrassing and uncomfortable problems, may dismiss their symptoms as natural processes of aging or chronic medical disease, or be unaware that effective treatments are available. It is imperative for healthcare providers to initiate directive questioning and to engage patients in frank discussion concerning sexuality and urogenital symptoms. Clinicians cannot treat a problem if they do not know that one exists.
Creating a comfortable, safe, warm environment where the patient can discuss concerns is paramount. Use of open ended questions and directed, follow up queries facilitates comprehension of medical issues. Allowing appropriate time for the questions and active listening can also elicit optimal responses from patients.
Clinicians that are uncomfortable with discussing or treating sexually-related complaints should develop community resources for referral. Continuing education focused on sexual history-taking or approaches to sexual dysfunction may also be helpful.
CONCLUSION
Women are living longer , healthier, productive lives, and are now expected to live about one third of their lives after menopause. Vaginal atrophy and related symptoms associated with natural or induced menopause, cancer treatment, lactation, medications, or chronic conditions warrant prompt identification, correct diagnosis, and optimal treatment. A variety of safe, effective treatment options are available . Careful assessment of the needs of individual needs and preference may facilitate successful treatment outcome. Sexuality can be enhanced , urologic functioning significantly improved, and quality of life positively affected when vaginal atrophy is recognized and treated.