New term which replaces vulvovaginal atrophy and atrophic vaginitis.
Describes the multiple changes occurring in external genitalia, urethra, pelvic floor, and its sequelae.
Caused by hypoestrogenism and loss of oestrogen during and after menopause, which does not recover.
Pathophysiology:
- Under-oestrogenised tissues lose elasticity and collagen
- Altered smooth muscle function
- Reduction in number of blood vessels and blood flow
- Thinning of epithelium
Anatomical and functional changes:
- Loss of labial and vulval fullness
- Contraction of labia majora
- Narrowing and stenosis of introitus
- Reduced elasticity and loss of hymenal remnants
- Vaginal shortening and narrowing
- Prolapse
- Weakening of pelvic floor
- Dry thin vaginal epithelium
- Loss of superficial cells, increase in parabasal cells
- Loss of vaginal rugae
- Alkaline pH changes vaginal microbiome, loss of Lactobacilli
- Thinning of urethral urothelium, prolapse and meatal prominence
- Loss of clitoral stimulation
Symptoms:
- Vaginal dryness and irritability
- Dyspareunia
- Prolapse
- Vaginal bleeding and discharge
- Recurrent UTI
- Urgency and frequency, urge incontinence
- Stress incontinence
- Dysuria
- Loss of libido
DDx:
- Lichen sclerosis
- Lichen planus
- Vaginismus or vulvodynia
- Malignancy
- OAB etc
Treatment:
- Education and reassurance
- Lubricants and vaginal moisturiser
- Non hormonal treatments – hyaluronic acid, vitamin E and vitamin D vaginal suppositories
- Topical oestrogens:
Topical oestrogens:
- Reduce symptoms
- Reverse atrophic changes
- Improve blood flow
- Improve tissue thickness and epithelial thickness
Negligible systemic absorption and no association with risks of oral hormonal treatment.
Breast cancer patients:
- Individualised risk-benefit discussion
- Consider discussion with patients oncologist
- Try non hormonal options first
- Little evidence of systemic absorption and no evidence of worse outcomes for breast cancer survivors, recognising that breast cancers can be oestrogen sensitive (80 % ER+)
- ACOG 2021 consensus statement
- “If non hormonal treatments have failed to adequately address symptoms, after discussion of risks and benefits, low-dose vaginal oestrogen may be used in individuals with history of breast cancer, including those taking tamoxifen”
- RANCZCOG “no consensus on use of vaginal oestrogens. Consult with breast surgeon or oncologist to optimise treatment options for individual patients”.