Atrophic Vaginitis: Etiology, Symptoms, Diagnosis, Treatment

Atrophic vaginitis is a complication of menopausal genitourinary syndrome, which is a constellation of signs and symptoms associated with a decrease in sex steroids, resulting in atrophic changes of the labia, clitoris, vaginal vestibule, vagina, vagina, urethra, and bladder.

Etiopathogenesis

Decreased levels of sex steroids, particularly estrogen, lead to atrophic changes in the vaginal mucosa and decreased glycogen deposition in the vaginal epithelium, which is metabolized by local bacterial communities to produce organic acids necessary for genital tract defense. As a result, the concentration of Lactobacillus decreases and, as a consequence, the pH level rises, which stimulates the growth of pathogenic bacteria leading to vaginitis.

Androgens (i.e., dehydroepiandrosterone, androstenedione, and testosterone) play an important role in vaginal mucosal metabolism and are required for estrogen biosynthesis. In healthy premenopausal women, androgen production is significantly higher than estrogen production. Androgen receptors are widely distributed throughout the urogenital tract. Androgen-dependent protein products have trophic effects on various tissues of the urogenital organs (vaginal vestibule, clitoris, urethra, vagina, bladder, pelvic floor muscles/ligaments). In addition to the cessation of estrogen production during menopause, the decrease in androgens with age may be a contributing factor to the signs and symptoms of genitourinary syndrome.

Clinical picture

Patients are bothered by genital dryness, burning and irritation. Sexual symptoms such as lack of discharge, decreased lubrication, discomfort, pain during intercourse or vaginal bleeding associated with sexual activity. As well as symptoms of urinary dysfunction, dysuria and recurrent urinary tract infections. It is worth saying that these symptoms in postmenopause have a negative impact on sexual interest, intimacy and relationship with a partner, mood and self-esteem.

Diagnosis of atrophic vaginitis

When examined in mirrors, thinning and smoothing of the vaginal mucosa, hyperemia, absence of discharge, the presence of local petechiae or ulcerative lesions are visualized.

The vaginal maturation index (VMI) is the proportional relationship between the superficial, intermediate, and parabasal cells of vaginal tissue. A decrease in estrogen is associated with an increase in parabasal cells, resulting in a decrease in VMI.

Histologic examination diagnoses a decrease in superficial squamous cells and an increase in parabasal cells. The hypoestrogenic state leads to loss of collagen, elastin fibers and blood vessels. These changes result in decreased elasticity and vascularization. Decreased vascularization in response to low estrogen levels leads to thinning of the vaginal mucosa and decreased discharge.

Treatment of atrophic vaginitis

Vaginal therapy

Vaginal therapy is the first-line pharmacologic treatment recommended by the International Menopause Society. Women should be started on the lowest dose and frequency that effectively manages their symptoms. The drug of choice is vaginal estrogen – this type of therapy is only appropriate for women with vaginal symptoms because this group of medications contains lower doses of estrogen than systemic therapy. Progestagen is generally not indicated for vaginal therapy. Endometrial surveillance is also not required unless there is postmenopausal bleeding that requires diagnostic evaluation. Vaginal therapy increases estrogen concentrations in the vaginal epithelium, uroepithelium, and helps reduce atrophic changes while minimizing systemic exposure. A Cochrane review showed no evidence of a difference in the proportion of women who reported improvement in symptoms between the following dosage forms: estrogen ring and estrogen cream, estrogen ring and estrogen pills, estrogen pills and estrogen cream. Estriol is a naturally occurring estrogen. A low dose of estriol vaginal gel (0.005%) has been shown to significantly increase vaginal cell maturation index and decrease vaginal pH compared to a control group in postmenopausal women.

Systemic therapy

1. Estrogen monotherapy is used in women after uterine extirpation.
2. Oral estrogen with progestogen therapy for women with an intact uterus.
3. Synthetic equivalent of endogenous dehydroepiandrosterone is approved for the treatment of moderate to severe dyspareunia. The drug is administered vaginally once a day. Use of the drug is associated with significant improvement in vaginal pH and vaginal symptoms. However, it is worth noting that serum estradiol and testosterone levels do not change. Visual examination demonstrates improvement in vaginal discharge, color, thickness and integrity of the epithelium. The safety of the effect on the endometrium of the intravaginal form of the drug has been demonstrated in short- and long-term studies. The most common adverse symptoms are abnormal vaginal discharge and abnormal Papanicolaou smear.
4. An oral selective estrogen receptor modulator approved for the treatment of dyspareunia and vaginal dryness. Preclinical data have shown that this drug may have favorable estrogenic effects on bone and anti-estrogenic effects on breast tissue. However, the drug is not approved for the prevention of osteoporosis or use in breast cancer. A meta-analysis of randomized trials showed that the drug is well tolerated and has a good safety profile.

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Symptomatic treatments

1. lubricants: women who do not wish to use vaginal estrogen can use non-hormonal lubricants and moisturizers. This therapy is aimed at short-term relief of vaginal dryness and dyspareunia. Water-based, silicone, mineral, or vegetable oil lubricants are applied to the vagina and vulva prior to intercourse.

2. Hyaluronic acid: the vaginal form of hyaluronic acid is a colorless gel that contains a derivative of hyaluronic acid that releases water molecules into the tissue, thereby relieving vaginal dryness without irritating the vaginal mucosa.

3. Physiotherapy/Dilators: Women with atrophic vaginitis and vaginal constriction can use a technique of gentle vaginal stretching using moistened dilators of various sizes. They will also be shown to perform exercises to train and relax the pelvic floor muscles.

4. Laser therapy: with fractional CO2 laser or erbium:YAG laser. Several small studies have shown that fractional CO2 laser therapy can restore the vaginal epithelium to a premenopausal-like state, increase lactobacillus counts. However, the world’s leading experts have not endorsed fractionated CO2 laser therapy and caution against its use for the treatment of genitourinary syndrome without long-term well-controlled studies.