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Menopause Matters

Vaginal Atrophy: Clinical Evaluation and Management

Rebecca S. Kightlinger, DO

Hypoestrogenism associated with menopause often causes the vaginal epithelium to become pale, dry, fragile, and less elastic„classic signs of vaginal atrophy. Reduced vaginal lubrication during sexual activity is often the first noticeable sign, usually with concomitant itching, burning, and pain. Superficial vulvovaginal fissures and vaginal petechiae may appear, increasing the likelihood of trauma, infection, bleeding, and pain. Inflammation of the atrophic vagina (ie, atrophic vaginitis) may also occur. Although this is not necessarily associated with infection, symptoms often mimic yeast infection or bacterial vaginosis.

Without treatment, vaginal atrophy may progress to significant thinning of the vaginal epithelium, with loss of subcutaneous fat in the labia majora, shrinkage and retraction of the clitoral prepuce, fusion of the labia minora, and stenosis of the introitus. At this stage of the condition, the woman may experience dyspareunia, postcoital bleeding, and chronic pain. Evaluation with pH testing and microscopy can help to identify atrophy, enabling the practitioner to treat confidently with local estrogen therapy.

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EVALUATION

Vaginal pH normally ranges between 3.8 and 4.5. Findings of 6.0 to 7.5 have been shown to correlate with atrophy, as indicated by a preponderance of parabasal cells on microscopy.¹

The normal acidic vaginal milieu is maintained during the reproductive years by the conversion of glucose to lactic acid and hydrogen peroxide by lactobacilli, using glycogen from desquamated superficial cells as substrate. Hypoestrogenism reduces the number of superficial cells, decreasing the glycogen available to the lactobacilli. As lactobacilli populations diminish, the vaginal environment becomes more alkaline, increasing vulnerability to opportunistic organisms. Administration of local estrogen promotes the maturation and glycogenation of vaginal epithelial cells, fostering recolonization of lactobacilli and restoring the normal pH.²

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NONHORMONAL TREATMENT

The clinical approach depends on the pattern and severity of the womanÍs symptoms, as well as her medical history and lifestyle. Nonhormonal products are the first-line treatments for mild symptoms of vaginal dryness. Water-soluble vaginal lubricants and moisturizers can decrease friction during sexual activity, and they are often sufficient to manage symptoms.

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ESTROGEN THERAPY

For women with moderate to severe vaginal atrophy, local estrogen therapy has been shown to restore vaginal blood flow, normalize pH, and improve both the thickness and elasticity of the vaginal tissues.³ All estrogen formulations approved by the US Food and Drug Administration (FDA) are indicated for the treatment of atrophic vaginitis. However, if the woman is not experiencing hot flashes or other menopause-related symptoms that require systemic estrogen therapy, a local (non- systemic) vaginal estrogen product„cream, ring, or tablet„is recommended. In clinical studies, these products have been shown to be as effective as systemic therapy for atrophic vaginitis.⁴

The vaginal delivery systems that deliver a local dose of estrogen must be clearly distinguished from estrogen therapies that deliver a systemic dose. Systemic doses are associated with more adverse effects and risks than nonsystemic products, and require a progestogen in women with a uterus. It should be noted that one of the vaginal rings (Femring) is included among the systemic (not local) vaginal delivery systems. Local vaginal estrogen delivery options are listed in the Table.

Table not available online

Table. Nonsystemic/Local Vaginal Estrogen Products

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Dosing

Treatment with vaginal estrogen cream (17b-estradiol, 2 to 4 g/d; conjugated equine estrogens, 0.5 to 2 g/d) usually consists of daily administration for 2 weeks. After that, the dose and frequency can be reduced to the lowest dose that maintains vaginal integrity.

The local-delivery vaginal estrogen ring releases 0.075 mg/d of 17b-estradiol for up to 90 days. After insertion, a surge in serum estrogen levels is measurable on the first day, but then levels drop to a range of 7.0 to 8.1 pg/mL, which is considered within normal menopausal levels (ie, less than 30 pg/mL).

The vaginal tablet may be preferred by women who find the vaginal creams messy or difficult to use. The 25 mcg estradiol hemihydrate tablet is initially dosed once daily for 2 weeks, followed by twice-weekly administration.

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ENDOMETRIAL EFFECTS

Studies have shown that even low doses of vaginal estrogen can lead to endometrial proliferation, hyperplasia, or carcinoma.⁵ However, there are currently no evidence-based recommendations for endometrial monitoring or progestogen dosing for women using unopposed low-dose local vaginal estrogen therapy.

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DURATION OF THERAPY

Women using local vaginal estrogen usually experience an improvement in vaginal health within a few weeks of beginning therapy. In some women, 4 to 6 weeks of therapy are needed before significant improvement is noted. Because of the chronic nature of atrophic vaginitis, long-term estrogen administration may be required for maintenance of vaginal health. Recommendations for hormone therapy from The North American Menopause Society⁶ acknowledge that the use of estrogen may be appropriate for women whose menopause-related vaginal symptoms adversely affect their quality of life, and for whom symptom relief outweighs risks.

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CONCLUSION

Menopause-related vaginal atrophy may profoundly affect intimacy, health status, and overall quality of life. For women whose symptoms do not respond sufficiently to nonhormonal treatment, local vaginal estrogen therapy remains a highly effective option.

Rebecca S. Kightlinger, DO, is Assistant Clinical Professor, University of Virginia, Charlottesville, and 2004/2005 Chair of the Consumer Education Committee of The North American Menopause Society.

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1. Brizzolara S, Killeen J, Severino R. Vaginal pH and parabasal cells in postmenopausal women. Obstet Gynecol. 1999;94(5 Pt 1):700-703.
2. Nilsson K, Risberg B, Heimer G. The vaginal epithelium in the postmenopause„cytology, histology and pH as methods of assessment. Maturitas. 1995;21(1):51-56.
3. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol. 1998;92 (4 Pt 2):722-727.
4. Keil K. Urogenital atrophy: diagnosis, sequelae, and management. Curr Womens Health Rep. 2002;2(4):305-311.
5. Weiderpass E, Baron JA, Adami HO, et al. Low-potency oestrogen and risk of endometrial cancer: a case-controlled study. Lancet. 1999;353(9167): 1824-1828.
6. The North American Menopause Society. Recommendations for estrogen and progestogen use in peri- and postmenopausal women: October 2004 position statement of The North American Menopause Society. Menopause. 2004; 11(6 Pt 1):589-600.

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