Vulvitis: Predisposing Factors, Clinical Manifestations, Diagnosis, and Treatment
Vulvitis refers to vulvar inflammation affecting the labia, clitoris, mons pubis, and vestibule of the vagina. Clinical manifestations, diagnosis, and treatment.
Atrophic Vaginitis: Etiology, Symptoms, Diagnosis, Treatment
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Atrophic vaginitis is a complication of genitourinary syndrome of menopause, which is a constellation of symptoms and clinical signs associated with declining levels of sex steroids that result in atrophic changes affecting the labia, clitoris, vaginal vestibule, vagina, urethra, and bladder.
Etiology and pathogenesis
A decline in sex steroid hormone levels, particularly estrogen, leads to atrophic changes in the vaginal mucosa and reduced glycogen deposition within the vaginal epithelium. Glycogen is metabolized by the local vaginal microbiota to produce organic acids that are essential for protecting the genital tract. As a result, the concentration of Lactobacillus decreases leading to an increase in vaginal pH, which promotes the growth of pathogenic bacteria and contributes to the development of vaginitis.
Androgens (i.e. dehydroepiandrosterone, androstenedione, and testosterone) play an important role in vaginal mucosal metabolism because they serve as precursors 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, and pelvic floor muscles/ligaments). In addition to the cessation of estrogen production during menopause, the age-related decline in androgen levels may also contribute to the development of the signs and symptoms of genitourinary syndrome.
Clinical Manifestations
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. Urinary symptoms may include 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
During a speculum examination, the vaginal mucosa appears thin and smooth, with erythema, absence of vaginal discharge, and the presence of localized petechiae or ulcerative lesions.
The Vaginal Maturation Index (VMI) reflects the proportional relationship among superficial, intermediate, and parabasal cells within the vaginal tissue. Estrogen deficiency is associated with an increased proportion of parabasal cells, resulting in a decreased 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.
Vaginal estrogen is the treatment of choice. This therapy is appropriate for women with isolated vaginal symptoms because vaginal estrogen preparations contain lower doses of estrogen than systemic hormone 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 systematic review found no evidence of differences in symptom improvement among women treated with the following vaginal estrogen formulations: estrogen vaginal ring versus estrogen cream, estrogen vaginal ring versus estrogen tablets, or estrogen tablets versus estrogen cream.
Estriol –is a natural 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
- Estrogen monotherapy is used in women who have undergone hysterectomy.
- Oral estrogen-progestogen therapy is recommended for women with an intact uterus.
- A synthetic equivalent of endogenous dehydroepiandrosterone has been 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 should be noted that serum estradiol and testosterone levels remain unchanged. 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 commonly reported adverse effects include abnormal vaginal discharge and abnormal Papanicolaou smear results.
- An oral selective estrogen receptor modulator has been 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
- Lubricants: Women who prefer not to use vaginal estrogen may use nonhormonal lubricants and vaginal moisturizers. This therapy is aimed at short-term relief of vaginal dryness and dyspareunia. Water-, silicone-, mineral oil-, or plant oil-based lubricants are applied to the vagina and vulva before sexual activity.
- Hyaluronic acid: Vaginal hyaluronic acid is available as a colorless gel containing a hyaluronic acid derivative that releases water molecules into the tissues, thereby relieving vaginal dryness without irritating the vaginal mucosa.
- Physical therapy/Vaginal dilators: Women with atrophic vaginitis and vaginal narrowing may benefit from gentle vaginal stretching using lubricated vaginal dilators of various sizes. Pelvic floor muscle training and relaxation exercises are also recommended.
- Laser therapy: Treatment with the use of 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.
FAQ
1. What is atrophic vaginitis?
Atrophic vaginitis is an inflammatory condition of the vaginal mucosa caused by estrogen deficiency. This condition is characteristic of the postmenopausal period and is marked by thinning of the vaginal epithelium, decreased secretory function, and alterations in the vaginal microbiota.
2. What symptoms are characteristic of atrophic vaginitis?
Typical symptoms include vaginal dryness, dyspareunia, pruritus, and burning. Genitourinary manifestations may include dysuria, frequent urination, and recurrent urinary tract infections. In severe cases, contact bleeding may occur.
3. What complications can develop if atrophic vaginitis is left untreated?
Progression of the atrophic changes may lead to chronic inflammation involving the lower urinary tract, the development of ulcerative mucosal lesions, and abnormal urination.
4. What preventive measures are recommended?
Preventive measures include regular pelvic examinations and maintenance of appropriate genital hygiene. Preventive use of intravaginal estrogen therapy may also be considered. Smoking cessation is recommended, as cigarette smoking causes vasoconstriction, leading to reduced vaginal secretions and exacerbation of symptoms.
5. Which age groups are most commonly affected by atrophic vaginitis?
Atrophic vaginitis occurs predominantly in postmenopausal women (typically after 50–55 years of age), with both the prevalence and severity of symptoms increasing progressively with age. Among older women (above 65 years of age), atrophic vaginitis is observed in approximately 60–70% of cases and is generally associated with a more severe clinical course. In women of reproductive age, the condition may develop in the setting of induced menopause (e.g. following bilateral oophorectomy or as a result of chemotherapy or pelvic radiation therapy) or in the presence of marked hypoestrogenism (e.g. due to hyperprolactinemia or anorexia nervosa).
References
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VOKA 3D Anatomy & Pathology – Complete Anatomy and Pathology 3D Atlas. VOKA 3D Anatomy & Pathology.
Available from: https://catalog.voka.io/
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Brotman RM, Shardell MD, Gajer P, Fadrosh D, Chang K, Silver MI, et al. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause. 2018 Nov;25(11):1321-1330.
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Cheng, R. Interpretation on the 2023 Chinese Menopause Symptom Management and Menopausal Hormone Therapy Guidelines. Med. J. Peking Union Med. Coll. Hosp. 2023, 14, 514–519.
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Partridge L, Deelen J, Slagboom PE. Facing up to the global challenges of ageing. Nature. 2018 Sep;561(7721):45–56. doi:10.1038/s41586-018-0457-8.
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Valadares ALR, Kulak Junior J, Paiva LHSC, Nasser EJ, da Silva CR, Nahas EAP, et al. Genitourinary syndrome of menopause. Rev Bras Ginecol Obstet. 2022;44:319-324.
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