Atrophic vaginitis


Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to low estrogen levels. Symptoms may include pain during penetrative sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination. It generally does not resolve without ongoing treatment. Complications may include urinary tract infections. Atrophic vaginitis as well as vulvovaginal atrophy, bladder and urethral dysfunctions are a group of conditions that constitute genitourinary syndrome of menopause. Diagnosis is typically based on symptoms.
The decrease in estrogen typically occurs following menopause. Other causes may include breastfeeding or using specific medications. Risk factors include smoking.
Treatment for atrophic vaginitis may involve the use of topical estrogen or other estrogen replacement. To treat the symptoms, patients may use lubricants, but it may not help long term as it does not affect the tissues.

Risk factors

In a majority of postmenopausal women, there are risk factors that can contribute to atrophic vaginitis. Specifically, these risk factors are directly related to decreased estrogen levels and vaginal health. Some risk factors include
  • Bilateral Oophorectomy: Women who undergo surgical removal of both ovaries, potentially causing a decline in estrogen levels.
  • Primary Ovarian Insufficiency: Ovaries fail to properly function before 40 years of age, causing a decrease in estrogen levels.
  • Ovarian Failure due to Radiation or Arterial Embolization: These treatments involve radiation or embolization of the ovaries and can cause ovarian damage. This leads to decreased estrogen production and symptoms of atrophic vaginitis.
  • Hypothalamic-Pituitary Disorders: These disorders directly affect the hypothalamus or pituitary gland, disrupting hormone production.
  • Anti-Estrogen Medications: Medications such as Danazol or Leuprolide can lower estrogen levels.
  • Postpartum Breastfeeding: Breastfeeding can cause lower estrogen levels due to hormonal changes.
  • Breast Cancer Survivors: Chemotherapy, selective estrogen receptor modulators, or aromatase inhibitors can lead to decreased estrogen levels and therefore side effects that include atrophic vaginitis.
  • Cigarette smoking
All of these factors impact estrogen levels and vaginal health, causing an increase in Atrophic vaginitis development.

Causes

Atrophic vaginitis may be caused by tissue thinning, loss of elasticity, and loss of vaginal fluids from low estrogen levels. Normally, estrogen helps the vagina shed old cells, which are then converted into lactic acid by good bacteria. This keeps the vagina's pH acidic and healthy. When estrogen levels drop, this process slows down, leading to thinner vaginal tissue, less moisture, and a less acidic environment. As a result, there's a higher risk of getting vaginal and urinary tract infections. Normal menopause and treatments such as chemotherapy or medications may result in loss of estrogen.
Those with or had a history of breast cancer may be at a higher risk of developing atrophic vaginitis due to chemotherapy and other endocrine treatments. Estrogen is crucial for women's sexual and urinary health. It supports the tissues in the lower vagina and urinary tracts to keep them thick, elastic, and moist and ensuring good blood flow. Estrogen helps maintain a thick, glycogen-rich vaginal lining, which healthy bacteria use to produce lactic acid to keep the vaginal environment acidic, reducing infection risks. In premenopausal women, the main form of estrogen is called estradiol and fluctuates between 40 and 200 pg/mL, rising to 600 pg/mL during ovulation. Postmenopause, estrogen levels drop significantly tp 5-18 pg/mL, leading to gradual changes in the urogenital area. All tissue types such as connective, epithelial, muscular, blood vessels, and nerves are affected and become thinner and less effective, which increases risk of infections, inflammation, injuries, and sores. Blood flow and sensation can decrease, causing pain during sex and the pH level can rise due to decreased lactic acid production, which can allow harmful bacteria and fungi to grow and cause infections.
Antiestrogen medications may also contribute to the development of atrophic vaginitis. These medications include danazol, nafarelin, and medroxyprogesterone. Additional risk factors include smokers, those who have not given birth naturally, and increased prolactin levels while lactation.

Signs and symptoms

After menopause the vaginal epithelium changes and becomes a few layers thick. Many of the signs and symptoms that accompany menopause occur in atrophic vaginitis. The earliest symptoms of atrophic vaginitis may be decreased vaginal lubrication, while other symptoms may appear later. Genitourinary symptoms include
It can be challenging to diagnose atrophic vaginitis given that the symptoms are mild and nonspecific for many postmenopausal women. Since women can have signs and symptoms that could be attributed to other causes, diagnosis is based upon the symptoms that cannot be better accounted for by another diagnosis.

Differential Diagnosis

To determine if atrophic vaginitis is the cause for a patient's symptoms, differential diagnosis may be used. Other diagnosis include bacterial vaginosis, trichomoniasis, candidiasis, and contact irritation from irritants such as soaps, pantyliners, or tight-fitting clothing. For example, a person who does not feel itching is unlikely to have candidiasis and no odor likely rules out bacterial vaginosis.

Clinical Examination

Lab tests usually do not provide information that will aid in diagnosing. A visual exam is useful. The observations of the following may indicate lower estrogen levels: little pubic hair, loss of the labial fat pad, thinning and resorption of the labia minora, and the narrowing of the vaginal opening. An internal exam will reveal the presence of low vaginal muscle tone, the lining of the vagina appears smooth, shiny, pale with loss of folds. The cervical fornices may have disappeared and the cervix can appear flush with the top of the vagina. Inflammation is apparent when the vaginal lining bleeds easily and appears swollen.

Lab Examination

The vaginal pH will change from being acidic to a more neutral pH at around 4.5 or higher. This is typically taken by placing Litmus test strip on the wall of the vagina. Papillary and reticular, as well as skin and dermal tissue atrophy are observed via histological examinations. Observed reduced vascularization, atrophy of epithelial tissue leading to reduced thickness, and paleness are all apparent in post-menopausal women during histological examinations. Microscopy laboratory tests may be used to rule out symptoms caused by trichomoniasis and other bacteria. A Papanicolaou test, also known as a pap test, would not be useful as it does not correlate strongly with the symptoms of atrophic vaginitis.

Vaginal Maturation Index (VMI)

The Vaginal Maturation Index is a measure used to assess the composition of different types of cells in the vaginal lining. It helps to evaluate the hormonal environment in the vagina by calculating the proportion of different types of cells present in the vagina. During different life stages, such as before the first menstural cycle, during reproductive years, and after menopause, the distribution of these cell types changes. VMI is determined using a specific formula and provides a more comprehensive view of the hormonal effects on the vagina over time than a single hormone level measurement. VMI is particularly useful in clinical research for evaluating the impact of hormone therapy and changes in sexual function during menopause. VMI is also a better measure of vaginal atrophy than patient-reported symptoms of vaginal dryness.

Treatment

Symptoms of genitourinary syndrome of menopause will unlikely be resolved without treatment. Some individuals may have many or a few symptoms so treatment is provided that best suits each person. If other health problems are also present, these can be taken into account when determining the best course of treatment. For those who have symptoms related to sexual activities, a lubricant may be sufficient. If both urinary and genital symptoms exist, local, low-dose estrogen therapy can be effective. Those individuals who are survivors of hormone-sensitive cancer may need to be treated more cautiously. Some people can have symptoms that are widespread and may be at risk for osteoporosis. Estrogen and adjuvants may be best. Recent research showed a medication called ospemifene can be an alternative oral treatment if vaginal products or hormone therapy is not suitable for patients surviving gynecological cancer. Ospemifene can increase collagen production to improve vaginal tissue, which will help reduce GSM symptoms. Studies have shown this medication has helped increase vaginal pH, elasticity, and moisture to improve vaginal health as well as sexual and emotional well-being.
Topical treatment with estrogen is effective when the symptoms are severe and relieves the disruption in pH to restore the microbiome of the vagina. When symptoms include those related to the urinary system, systematic treatment can be used. Recommendations for the use of the lowest effective dose for the shortest duration help to prevent adverse endometrial effects. Treatment is generally with estrogen cream applied to the vagina. The use of estrogen for treatment do come at some risk. Those who are treated with estrogen may be at a higher risk of developing vaginal candidiasis since estrogen allows lactobacilli to increase in levels. Additionally, it is recommended that soaps and other irritants are avoided.
Some treatments have been developed more recently. These include selective estrogen receptor modulators, vaginal dehydroepiandrosterone, and laser therapy. Other treatments are available without a prescription such as vaginal lubricants and moisturizers. Vaginal dilators may be helpful. Since GSM may also cause urinary problems related to pelvic floor dysfunction, the person may benefit from pelvic floor strengthening exercises. The individual and their partners have reported that estrogen therapy resulted in less painful sex, more satisfaction with sex, and an improvement in their sex life. If a person cannot tolerate or use estrogen therapy, topical hyaluronic acid can be used as another option which has been shown to be safe and effective. For mild atrophic vaginitis, hyaluronic acid can be used as a treatment first. However, if it is moderate to severe atrophic vaginitis, estrogen therapy is recommended to be used first. Vitamin E vaginal suppositories were also found to be helpful in relieving symptoms of GSM, but further studies need to be done to evaluate how safe and effective this treatment is for this condition. Other studies have discussed using vaginal oxytocin as a treatment, but there has been no significant effect on GSM in either helping alleviate signs and symptoms or improving the condition.