Vulvovaginitis due to estrogen de-ficiency

Notes

## Basic introduction

  • It mainly affects postmenopausal females (average age of menopause = 51.3yrs) with 20% of cases being serious enough to warrant treatment.

## Causes of estrogen deficiency:

  • Surgical or natural menopause
  • Drugs such as GTRH
  • Premature ovarian failure that may be due to chemotherapy, irradiation and autoimmunity
  • Postpartum period and lactation (due to hypoestrogenic state that is caused by the high levels of prolactin)

## Pathophysiology

  • The basis of pathophysiology is the general reduction of estrogen levels in the body, including vagina and vulva
  • This leads to the reduced blood flow, lubrication, vaginal and vulvar fullness, and mechanical sensitivity
  • There is also reduced vaginal cell maturation that leads to the thinning of vaginal mucosa and reduced glycogen stores (that affects vaginal pH and flora).
Symptoms
  • Burning sensation
  • Dyspareunia
  • Dysuria
  • Foul-smelling discharge
  • Hematuria
  • Increased urinary frequency
  • Bacterial or fungal infections
  • Pruritus
  • Pale, smooth or shiny vaginal epithelium
  • Stress incontinence
  • Tenderness
  • Vaginal dryness
  • Sore and cracks
  • Fusion of labia minora
  • Bleeding after sexual intercourse
  • Introital stenosis (stenosis of the opening of the vagina, introitus)
  • Sparsity of pubic hair
  • Reduced vaginal lubrication
  • Reduced vaginal and vulvar fullness
  • Wrinkled vulva and vagina
  • Vaginal pH < 5
  • High levels of plasma FSH
  • Low levels of plasma estrogen
  • Wet preparation/cytologic smear of cells from upper 1/3 of vagina reveals atrophic cytologic changes such as increase in proportion of parabasal cells
Diagnosis
  • Clinical review including vuvovaginal examination
  • Wet preparation/cytologic smear of cells from upper 1/3 of vagina
  • Vaginal pH
  • Levels of plasma FSH
  • Levels of plasma estrogen
Differential
  • Bacterial or yeast vulvovaginitis
  • Malignancy
  • Vulvar dystrophies
  • Exposure to irritants
Prevention
  • Women who are sexually active report fewer symptoms of atrophic vaginitis
Reference
  1. Farquhar CM, et al. Long-term hormone therapy for premenopausal and postmenopausal women. Cochrane Database Sys Rev. 2005;3:CD004143
  2. Greendale GA, Judd HL. The menopause: health implications and clinical management. J Am Geriatr Soc. 1993; 41:426–36.
Management
  • Vaginal estrogen cream or tablets: Insert vaginally using an applicator Nocte x 2/52 then repeat at an interval of 2-3wks (improvement will be observed within 30 - 60 days)
  • Estradiol-containing vaginal ring: Insert into vagina, and replace at an interval of 3 months
  • Use systemic estrogen therapy only if there are vasomotor symptoms
  • Water-soluble lubricants or vaginal moisturizers may be useful in relieving the symptom of dryness
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