VULVOVAGINITIS, ESTROGEN DEFICIENT

Maria De La Luz Nieto, MD

 BASICS

DESCRIPTION

•  Vaginal atrophy is due to decreased blood flow to vaginal epithelium, resulting in thinning of the female genital tissues.

•  Estrogen deficiency affects all tissues in the female body; however, the genital tissues are especially hormone-responsive and are most affected, leading to atrophy.

•  Patients with estrogen-deficient vulvovaginitis may present with urinary incontinence, vaginal burning and itching, dyspareunia, increased urinary frequency, or recurrent UTIs.

•  System(s) affected: reproductive

EPIDEMIOLOGY

Incidence

•  Predominant age: postmenopausal females. The average age of menopause in the United States is 51.3 years but ranges from 45 to 55 years old.

•  May affect lactating women

•  Predominant sex: female only

•  May occur in younger women with premature ovarian failure

Prevalence

•  Most postmenopausal women are affected to some degree.

•  Up to 40% of postmenopausal women experience symptoms severe enough to seek treatment.

ETIOLOGY AND PATHOPHYSIOLOGY

•  Decreased estrogen levels in the vagina and vulva result in decreased blood flow and decreased lubrication of vaginal and vulvar tissue.

•  Vaginal and vulvar tissues become thin secondary to decreased vaginal cell maturation.

•  Decreased cellular maturation results in decreased glycogen stores, which affects the normal vaginal flora and pH.

•  Estrogen deficiency due to the following:

–  Menopause (surgical or natural)

–  Premature ovarian failure (chemotherapy, irradiation, autoimmune, anorexia, genetic)

–  Postpartum, lactation

–  Medications that alter hormonal concentration, such as gonadotropin-releasing hormone agonists, and antiestrogens, such as tamoxifen and danazol

–  Elevated prolactin from hypothalamic–pituitary disorders

Genetics

No known pattern

RISK FACTORS

Estrogen-deficient states

COMMONLY ASSOCIATED CONDITIONS

•  Urge and stress urinary incontinence

•  Pelvic organ prolapse

•  Frequent UTIs

•  Bacterial vaginosis or yeast infections

 DIAGNOSIS

HISTORY

•  All female patients should be asked about symptoms because many women are embarrassed to discuss these issues with their health care providers (1)[C].

–  Vaginal dryness

–  Dyspareunia

–  Pruritus

–  Burning

–  Pressure

–  Tenderness

–  Malodorous discharge

–  Urinary symptoms: dysuria, hematuria, frequency, infections, stress, and urge urinary incontinence

•  Ask about self-treatment and products used.

•  Determine exposure to irritants (e.g., soaps, feminine sprays, lotions, lubricants, constant pad use).

PHYSICAL EXAM

Evidence for the diagnosis includes the following:

•  Loss of pubic hair

•  Decreased vulvar and vaginal fullness

•  Decreased vulvar subcuticular fat and moisture

•  Pale-appearing, shiny, smooth vaginal and urethral epithelium

•  Vaginal shortening, intolerance to speculum exams

•  Loss of vaginal rugation

•  Pelvic organ prolapse

•  Shorten urethra

DIFFERENTIAL DIAGNOSIS

•  Malignancy

•  Dermatologic conditions of vulva and vagina:

–  Dermatitis

–  Lichen sclerosis

–  Lichen planus

•  Bacterial or yeast vulvovaginitis

DIAGNOSTIC TESTS & INTERPRETATION

Because vulvovaginitis is a clinical diagnosis, labs are not always necessary, but if suspect dermatologic or oncologic condition, biopsy is recommended (2)[A].

Initial Tests (lab, imaging)

However, the following labs may be obtained as corroborative of clinical impression:

•  Check follicle-stimulating hormone (FSH) and estrogen levels. FSH rises and estrogen drops with menopause.

•  Evaluate for infections via wet preparation and vaginal pH (usually >5).

•  Urine dip and urinalysis if suspected concomitant UTI

•  Perform cytology for maturation index: Higher proportion of parabasal cells and lower proportion of intermediate and superficial cells indicate decreased maturation index.

Follow-Up Tests & Special Considerations

Drugs that may alter lab results:

•  Estrogen therapy will alter the maturation index.

•  Digoxin has estrogen-like properties.

•  Tamoxifen may produce menopausal-type symptoms but also may act on genital tissues as a weak estrogen agonist.

•  Progestins, danazol, and gonadotropin-releasing hormone agonists may produce a reversible pseudomenopause state.

Test Interpretation

•  Thinning of the cornified squamous layer of both the vulva and the vagina

•  Increased parabasal cells

•  Compact underlying collagenous tissue

 TREATMENT

GENERAL MEASURES

•  Wear loose-fitting, undyed cotton underwear.

•  Avoid prolonged pad use, especially scented pads.

•  Avoid feminine deodorant sprays and douching.

•  Use over-the-counter water-based lubricants, as needed.

•  Symptomatic relief, if needed (e.g., cool baths or compresses)

MEDICATION

•  Vaginal estrogen can reverse atrophic changes and help to alleviate symptoms (3)[A].

–  Vaginal cream 1 g (conjugated equine estrogens or estradiol cream): Insert via applicator each night for 14 days and then 2 to 3 times per week.

–  Vaginal estradiol 10-μg tablet: Insert via preloaded applicator each night for 14 days and then 2 to 3 times per week.

–  Estradiol-containing vaginal ring 2 mg: Insert into vagina, and replace every 3 months.

•  Estrogen therapy should be used in the lowest possible dose for the shortest duration of time (4)[B].

•  Long-term therapy may be necessary owing to the chronic nature of estrogen-deficient vulvovaginitis (5)[A].

•  Systemic therapy typically is used as hormonal treatment of vasomotor symptoms and not for the primary treatment of estrogen-deficient vulvovaginitis.

•  Contraindications

–  Breast or estrogen-dependent carcinoma

–  Undiagnosed vaginal bleeding

–  Thromboembolic disorders

–  Thrombophlebitis

–  Pregnancy

•  Precautions: Any abnormal vaginal bleeding must be evaluated.

•  Nonestrogen therapy: estrogen agonist/antagonist (6)[B]

–  Ospemifene (Osphena) 60-mg tablet daily

•  Contraindications

–  Breast or estrogen-dependent carcinoma

–  Undiagnosed vaginal bleeding

–  Thromboembolic disorders

–  Thrombophlebitis

–  Hepatic impairment

•  Precautions: Any abnormal vaginal bleeding must be evaluated, monitor for DVT and stroke.

ISSUES FOR REFERRAL

•  Refer to urogynecologist for evaluation if symptomatic due to pelvic organ prolapse and/or stress and urge urinary incontinence.

•  Recurrent UTIs should be referred to urogynecology and/or urology for evaluation.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Outpatient treatment

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

No restrictions

Patient Monitoring

Instruct the patient that symptoms should improve within 30 to 60 days. If they do not, reevaluate and reexamine for other causes.

DIET

No special diet

PATIENT EDUCATION

•  American College of Obstetricians and Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; 800-762-ACOG: http://www.acog.org/

•  Lactating postpartum women with high levels of prolactin are in a hypoestrogenic state. These women should be instructed to use lubrication for symptoms of dyspareunia and reassured that the symptoms will resolve when they are no longer breastfeeding.

PROGNOSIS

The prognosis is excellent. Most symptoms will be alleviated with vaginal estrogen replacement therapy.

COMPLICATIONS

•  Recurrent UTIs may occur in women with vaginal atrophy.

•  Vaginal atrophy predisposes patients to vaginal infections.

REFERENCES

1.  Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol. 2008;51(3):549–555.

2.  Johnston SL, Farrell SA, Bouchard C, et al. The detection and management of vaginal atrophy. J Obstet Gynaecol Can. 2004;26(5):503–515.

3.  Farquhar CM, Marjoribanks J, Lethaby A, et al. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2005;(3):CD004143.

4.  Ibe C, Simon JA. Vulvovaginal atrophy: current and future therapies (CME). J Sex Med. 2010;7(3):1042–1050.

5.  Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006;(4):CD001500.

6.  Constantine G, Graham S, Portman DJ, et al. Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: results of a randomized, placebo-controlled trial. Climacteric. 2015;18(2):226–232.

 CODES

ICD10

•  N95.2 Postmenopausal atrophic vaginitis

•  E28.39 Other primary ovarian failure

CLINICAL PEARLS

•  Estrogen-deficient vulvovaginitis affects virtually all postmenopausal women to some degree.

•  This disorder is often associated with urinary incontinence, increased urinary frequency, and recurrent UTIs.

•  Lab tests are generally unnecessary to make the diagnosis.

•  Vaginal estrogen preparations, rather than systemic preparations, should be the first-line therapy in a woman whose primary complaint is associated with vaginal atrophy.