The Warren Alpert Medical School of Brown University GERI A TRI C S FOR THE Division of Geriatrics PR ac TI C ING PHYSICIAN Quality Partners of RI Department of Medicine EDITED B Y AN A Tuya FU LTON , MD Vulvovaginal Atrophy: A Common—and Commonly Overlooked— Problem Mary H. Hohenhaus, MD, FACP Mrs. K is a 67-year-old woman presenting for a brief All postmenopausal women are at risk for vaginal atrophy. follow-up visit. You treated her for an E. coli urinary Smokers are more estrogen deficient compared with nonsmok- tract infection last month, but she feels well today and ers and may be at higher risk. Engaging in regular sexual activ- offers no complaints. Her blood pressure and lipids ity, whether through intercourse or masturbation, appears to are well controlled on low doses of a single antihyper- decrease risk, possibly through increased blood flow. Women tensive and a lipid lowering agent. She still struggles using anti-estrogen medications, such as aromatase inhibitors with smoking, but has cut down to a few cigarettes a for adjuvant treatment of breast cancer, are more likely to experi- day. She also reports her husband has finally turned ence severe symptoms. over the family business to their children, and they Women may not volunteer symptoms related to vulvovagi- are enjoying spending more time together. When you nal atrophy. The symptomatic woman can experience vaginal ask if there is anything else she needs, she hesitates dryness, burning, and pruritus; yellow, malodorous discharge; for a moment before asking, “Is there anything I can urinary frequency and urgency; and pain during intercourse and do to make sex more comfortable?” bloody spotting afterward. With advanced atrophy, penetration On further questioning, Mrs. K states she and during intercourse may be impossible. Recurrent urinary tract her husband have become more intimate since his infections may occur. retirement, but that attempts at intercourse have Typical findings on external genital exam include sparse been painful and caused bleeding. At times her pubic hair, decreased turgor and elasticity of the vulva, fusion vagina is dry and burns, but at other times there is a of the labia minora, and eversion of the urethral mucosa. The thin yellow discharge. An over-the-counter douche vaginal exam should be approached carefully, with evaluation made the burning worse. A friend suggested an herbal of the width and depth of the introitus before attempting to supplement which she tried for a few weeks without insert a speculum. A narrow Pederson speculum is a better success. She used to enjoy sex but is concerned that choice than the broader Graves speculum. The vaginal exam part of her life “is over for good.” You suspect her shows pale, smooth, shiny mucosa that may be friable and complaints are related to vulvovaginal atrophy. bleed with minimal trauma. The vagina may be dry or there may be watery to serosanguinous discharge. Fissures, diffuse Vulvovaginal atrophy, also known as atrophic vaginitis, results or patchy erythema, petechiae, or visible vessels are common from the decline in endogenous estrogen secretion after meno- findings. Cystocele, rectocele, or uterine prolapse may also pause, which induces thinning of the vulvovaginal epithelium be present. with associated inflammatory changes. It is common in older Vulvovaginal atrophy is primarily a clinical diagnosis in women but not always symptomatic. Unlike vasomotor symp- older women, but select testing can help rule out coexisting toms, which occur early in menopause and usually resolve, vul- conditions suggested by specific symptoms: vovaginal atrophy presents later and is persistent and progressive. True incidence and prevalence are unknown. Estimates suggest • Urinary urgency or frequency: urinalysis and culture to up to half of postmenopausal women are symptomatic, but a rule out urinary tract infection quarter of these will not seek treatment. • Vaginal discharge: microscopy of saline and potassium Estrogen is essential to maintaining the urogenital envi- hydroxide wet preps to evaluate for bacterial vaginosis ronment. After menopause, the vaginal epithelium thins while and vaginal candidiasis subepithelial connective tissue increases, resulting in loss of • Postcoital spotting: cervical cultures or urine testing for rugal folds and elasticity. Vaginal epithelium is a rich source of gonorrhea and chlamydia glycogen, which in turn supports lactic-acid producing bacteria. • Vaginal bleeding: transvaginal ultrasound to evaluate The loss of lactobacilli and subsequent increase in vaginal pH for endometrial overgrowth that accompany estrogen deficiency allows overgrowth of gram • Labial or vaginal wall lesions: biopsy to evaluate for negative rods, which may predispose to urinary tract infection. dermatologic conditions such as lichen planus or ma- Finally, blood flow is reduced, producing a decline in vaginal lignancy secretions. 138 MEDICINE & HEALTH/RHODE ISLAND Table 1. Topical estrogen therapy for vaginal atrophy Whether treatment is needed in asymptomatic women is Estrogen exposure is assumed to be minimized with topi- unknown. Lifestyle modification and over-the-counter vaginal cal therapy, but systemic absorption does occur. Creams have moisturizers and lubricants should be considered as first-line the highest association with systemic absorption, followed by treatment. Women should be counseled to avoid tight-fitting tablets then rings. Safety beyond one year is unknown. Use of clothing, synthetic undergarments, and contact irritants such the lowest effective dose for the shortest duration possible is as scented soaps and feminine hygiene products. Regular use of recommended. vaginal moisturizers (such as Replens) can help relieve vaginal Although endometrial protection is not routinely recom- itching and irritation, while water- or silicone-based personal mended, addition of a cyclic or daily progestin to prevent en- lubricants (such as Astroglide or Eros) during intercourse can dometrial hyperplasia should be considered with long-term or reduce dyspareunia. higher dose (>0.5 mg estradiol or >0.5 g conjugated estrogens/ Estrogen-based treatment restores vaginal epithelium, pH, day) topical therapy. and moisture, and should be considered when non-hormonal Estrogen is contraindicated in known or suspected breast or treatments fail. Although there are few well-designed trials, other estrogen-dependent cancers, undiagnosed vaginal bleeding, topical therapy is preferred for isolated vaginal symptoms given history of thromboembolism, or active thrombophlebitis. Use concern for long-term risks of malignancy and cardiovascular in a woman with breast cancer with severe urogenital atrophy disease with systemic hormone replacement therapy (HRT). unresponsive to non-hormonal treatment should be consid- Local estrogen treatment may also be helpful in women ered only after careful discussion of risks with the woman and taking ultra-low-dose HRT for vasomotor symptoms. If her oncologist. There is additional concern for women using urogenital symptoms are not relieved, the addition of topical adjuvant therapy for breast cancer as there may be sufficient estrogen may limit total estrogen dose compared with use of systemic absorption from topical estrogen to counteract the higher dose HRT. anti-estrogenic effects of aromatase inhibitors. Topical estrogen is available in several forms (see table). Estrogen use should be reviewed every 3 to 6 months, with There are insufficient data to recommend any single treatment an attempt to taper or discontinue its use. Discontinuation often as superior, so patient preference should guide selection. Vaginal results in symptom recurrence. Women using estrogen should symptoms typically respond within a few weeks. Side effects may have an annual clinical breast exam and mammography. Vaginal include breast and perineal pain, local irritation, and endometrial bleeding should prompt transvaginal ultrasound to evaluate for proliferation. endometrial overgrowth, with endometrial biopsy as indicated. 139 VOLUME 94 NO. 5 MAY 2011 The need for surveillance ultrasound in asymptomatic women RESO U R C ES is unknown. North American Menopause Society. The role of local There has been considerable interest in bioidentical hor- vaginal estrogen for treatment of vaginal atrophy in postmeno- mones as well as complementary medications, including phy- pausal women: 2007 position statement of The North American toestrogens, black cohosh, dong quai, ginseng, and red clover, Menopause Society. Menopause 2007;14(3):357-369. but data on their effectiveness are limited. Suckling JA, Kennedy R, Lethaby A, Roberts H. Local Vulvoaginal atrophy is a common, but often unrecognized, oestrogen for vaginal atrophy in postmenopausal women. Co- condition in older women that can significantly affect daily life. chrane Database of Systematic Reviews 2009, Issue 1. Art. No.: Clinicians who care for older women should be alert to possible CD001500. DOI 10.1002/14651858.CD001500.pub2. clues and specifically inquire about symptoms. Effective inter- Kendall A, Dowsett M, Folkerd E, Smith I. Caution: vagi- ventions are available, although more study is needed regarding nal estradiol appears to be contraindicated in postmenopausal the long-term safety of topical estrogens. Given concerns for women on adjuvant aromatase inhibitors. Annals of Oncology systemic effects of topical estrogens, there is significant research 2006;17:584-587. interest in more targeted therapies, such as vaginally delivered Simon