Vulvovaginal atrophy: An inevitable consequence of aging?

According to the North American Menopause Society (NAMS), as of 2010 more than 64 million women in the United States will be in the menopausal age range.¹ Since publication of the Women’s Health Initiative (WHI), however, some clinicians and patients have avoided use of systemic hormone therapy (HT) for menopausal symptoms. As a result, many women suffering from menopausal symptoms, such as hot flashes and vaginal dryness, seek no treatment as they fear that none is available. As more data are published from the WHI, the pendulum has begun to swing back, favoring use of HT for symptomatic women. NAMS recommends using the lowest effective dose for the shortest duration of time as it relates to treatment goals for the individual.

Much attention is focused on the hot flashes and night sweats that often accompany estrogen loss during the menopausal transition. Vaginal health, however, has long been overlooked as an inevitable consequence of aging.

Vulvovaginal changes with age

The vulva and vagina contain the largest tissue concentration of estrogen receptors in the female body. As a girl goes through puberty, estrogen is produced by the ovary. The labia thicken and develop, the mons elevates, and internal genital organs develop. The vagina matures and develops a multilayered epithelium with rugae, or folds of tissue facilitating distention during intercourse. The pH of the vagina becomes acidic, around 3.5 or lower, indicating the presence of hydrogen peroxide–producing lactobacilli. These protective bacteria keep opportunistic pathogens at bay, ensuring the healthy vaginal ecosystem. Normal vaginal discharge is relatively odor free, thin, and nonirritating.

As a woman goes through perimenopause and enters menopause, endogenous estrogen levels decrease. The labia begin lose characteristic thickness and become thin. The vaginal introitus can stenose, making intercourse painful (dyspareunia) or impossible. The vaginal epithelium becomes thin and can be friable. Rugation decreases, making the vaginal vault shorter and narrower, another contributor to dyspareunia (Table 1). The pH increases, as lactobacilli decrease in the absence of estrogen. Consequences may include vaginitis from opportunistic flora and Escherichia coli colonization of the urethra, placing the woman at a higher risk of cystitis and urinary tract infections.²

Table 1. Signs and symptoms of vaginal atrophy

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse
• Shortening and tightening of the vaginal canal

Mayo Clinic. Vaginal atrophy: symptoms. September 19, 2008. http://www.mayoclinic.com/health/vaginal-atrophy/DS00770/DSECTION=symptoms. Accessed October 12, 2009.

Vaginal health: An often-avoided topic

Many women are reluctant to discuss vaginal discomfort or sexual health issues with their health care provider. And clinicians may be hesitant to broach the subject. As a result, women often live with this discomfort, believing that the clinician will be uncomfortable discussing the problem, that this is “normal” for an aging woman, or that no treatment options are available.

Ways to facilitate a dialogue with patients

Several strategies are available to clinicians to facilitate discussion about vaginal health. Often patients respond to questionnaires regarding sensitive topics, including sexual health concerns. Another option is to discuss with the patient what is seen during visual inspection and the speculum exam. Determining vaginal pH can help initiate discussion, as can observation regarding vaginal irritation or dryness. Comments that may help open the conversation include the following examples:
“It appears that you have some vaginal irritation.”
“Have you had any symptoms of burning or dryness?”
“Has sex been more uncomfortable lately?”

Treatment options

Fortunately, multiple therapies are available for treatment of the symptoms of vulvovaginal atrophy (Table 2).³ Topical vaginal estrogen therapy is available in cream and tablet form(s), or as a ring that releases a consistent dose of estrogen while in place and needs to be replaced about every 3 months. NAMS advocates for use of a topical therapy for women who experience vulvovaginal symptoms exclusively. Used in recommended doses, these therapies have no systemic influence and do not need to be opposed with a progestin in women who have an intact uterus. Vaginal estrogen cream can also be applied to the vaginal introitus and fourchette. Estrogenization of these tissues can expedite treatment of dyspareunia, and prevent/treat introital stenosis.

Table 2. Treatment options for vulvovaginal atrophy

Mayo Clinic. Vaginal atrophy: symptoms. September 19, 2008. http://www.mayoclinic.com/health/vaginal-atrophy/DS00770/DSECTION=symptoms. Accessed October 12, 2009.

For women who are unwilling or unable to use estrogen, for example, women with a history of estrogen-dependent neoplasia(s), several vaginal moisturizers are available over the counter. Replens is a brand that is commonly recommended. RepHresh may be used in an effort to restore an acidic vaginal pH.

Women should be encouraged to continue having regular vaginal intercourse, once dyspareunia has improved. The “use it or lose it” theory definitely applies here! Women who engage in regular intercourse are at decreased risk of introital stenosis and vaginal atrophy compared with women who are abstinent.

The use of a vaginal lubricant during intercourse should be reinforced. Some of the water-based lubricants may have a drying effect on the vagina, so oil-based lubricants may be more soothing and effective. If concern about sexually transmitted infections exists, water-based lubricants are mandatory, as these will not compromise the integrity of latex condoms.

R E F E R E N C E S

1. North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy: 2007 position statement of The North American Menopause Society. Menopause. 2007:14:355-356.
2. Davila GW, Singh A, Karapanagiotou I, et al. Are women with vaginal atrophy symptomatic? Am J Obstet Gynecol. 2003;188:382-388.
3. Mayo Clinic. Vaginal atrophy: symptoms. September 19, 2008. http://www.mayoclinic.com/health/vaginal-atrophy/DS00770/DSECTION=symptoms. Accessed October 12, 2009.