Introduction
- The female genital tract (vulva, vestibule, cervix and uterus) and the bladder and urethra are rich in estrogen receptors.
- The decline in estrogen levels results in reduced blood flow to the epithelium of the vulva, vestibule, vagina and cervix.
- Superficial to parabasal cell proportion decreases with the loss of glycogen and lactobacilli, causing the skin in the area to become thin and vulnerable.
- Vaginal pH can increase to 6–8 (from 4–5 in the premenopausal status), making the vagina more susceptible to infection.
- Menopause can influence and alter expression of genes involved in extracellular matrix metabolism in the vagina.
- Vaginal estrogen deficiency can have a profound effect on quality of life.
- Vulvovaginal atrophy continues to be under recognized and undertreated
Symptoms
- vaginal dryness (75%)
- dyspareunia (40%)
- vulval and vaginal pruritis
- discharge
- Urinary symptoms
- urinary frequency and urgency, nocturia, dysuria and incontinence.
Recurrent urinary tract infections occur in up to 20% of postmenopausal women
Diagnosis
Assessment tools have been developed to facilitate the formal diagnosis and classification of the severity of VVA.
- Vaginal Health Index is commonly used:
clinicians rate both the appearance of the vaginal mucosa and production of secretions on a scale of 1–5.
- Genitourinary Syndrome of Menopause (GSM)- The GSM assessment tool
The score system refers to the degree of atrophy rather than the ‘syndrome’ itself.
This tool has not yet been validated and is therefore not in routine use
Treatment
- Vaginal lubricants and moisturisers
| Lubricants | Moisturisers |
| water-based, plant oil based, mineral oil-based or silicone-based products. oil-based and silicone-based lubricants are thicker in composition and longer lasting compared with water-based lubricants. Oil-based preparations can break down latex condoms | Vaginal moisturisers imitate natural secretions by rehydrating the mucosal layer and adhering to the vaginal lining. Long lasting compared with lubricants, if used regularly. Use in painful intercourse, but also by symptomatic women who are not sexually active. |
- Phytoestrogens
- Intravaginal application (isoflavin gel) and oral preparations
- Intravaginal preparation, has shown some positive effects on the vaginal epithelium than oral.
- Isoflavone gel and estrogen showed similar improvements in vaginal dryness and dyspareunia.
- phytoestrogens should be used with caution in women who have contraindications to estrogen.
- Vaginal laser treatment
- Vaginal erbium and CO2 lasers have been used to treat VVA.
- Vaginal laser stimulates cellular proliferation and viability of the vaginal epithelium.
- Erbium laser is an effective treatment for VVA in breast cancer survivors
- Local and systemic hormone replacement therapy
- Stimulates revascularisation and regeneration of the collagen of vaginal and lower urinary tract epithelium.
- Systemic HRT is best used in the presence of vasomotor symptoms or osteoporosis.
- Currently, it is advised that the lowest possible dose that provides effective relief of symptoms should be used as maintenance therapy.
- Vaginal estrogen therapy improves sexual function in postmenopausal women with VVA (vulvo vaginal atropy). The REJOICE trial concluded that vaginal estradiol soft gel capsules were safe and effective for the treatment of moderate to severe dyspareunia in women suffering from vaginal atrophy.
- Selective estrogen receptor modulators and tissue-selective estrogen complexes
- Raloxifene and tamoxifen are not effective in the treatment of VVA. Ospemifene and lasofoxifene, which were originally used to treat postmenopausal osteoporosis, have positive effects on vaginal epithelium and can therefore reduce the symptoms of VVA.
- Lasofoxifene significantly reduced symptoms of moderate to severe VVA over the course of 12 weeks.
- Conjugated estrogens with bazedoxifene (CE/BZA) improved vaginal atrophy with reduced incidence of dyspareunia
- Androgens and dehydroepiandrosterone
- 4-week course of vaginal testosterone improved signs and symptoms of vaginal atrophy without an increase in systemic estradiol levels.
- It is safe and effective
- Dehydroepiandrosterone (DHEA) is a precursor steroid in the biosynthesis of sex steroids. Oral and vaginal preparations of DHEA can improve symptoms of VVA.
- Intravaginal DHEA does not seem to increase the levels of sex steroids beyond those normally found in menopause.
- Prasterone is now licensed in the USA for the treatment of moderate to severe dyspareunia.
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