II. Epidemiology
- Prevalence: 50% of post-menopausal women within first 3 years
III. Causes
-
Menopause (most common)
- Vulvovaginal Atrophy and dryness symptomatic in 50% of postmenopausal women (due to low Estrogen)
- Only 25% of symptomatic women seek medical care
- Antiestrogen medications (e.g. Raloxifene, Tamoxifen, GnRH Agonists)
- Premature Ovarian Failure
- Breast Feeding women
- Central Amenorrhea
IV. Pathophysiology
- Related to decreased Estrogen with Menopause
- Vaginal effects
- Vaginal epithelium thins with decreased lubrication
- Vaginal canal narrowing
- Bleeding or pain on intercourse
- Vulvar mucosa thinning
- Vulvar burning or irritation
- Dyspareunia due to introitus narrowing
- Glycogen loss with altered Vaginal pH and flora
V. Symptoms
- Vaginal Dryness
- Vaginal or vulvar burning, itching or irritation
- Dyspareunia
- Vaginal Discharge
- Urinary urgency
- Urge Incontinence
VI. Signs
- Vaginal Discharge that is thin or clear
- Vaginal introitus narrowing
- Loss of labia minora
- Vaginal mucosa changes
- Mucosa is thin, pale and dry with reduced elasticity
- Vaginal rugae lost
- Mucosa may be irritated and friable
VII. Labs
- Vaginal pH 5 to 7
VIII. Complications
IX. Management: Primary
- See Menopause
- Symptomatic measures (first-line for mild symptoms)
- Vaginal Moisturizers (Replens) applied three times weekly
- Vaginal Lubricant (e.g. Astroglide) applied before intercourse
- Topical Vaginal Estrogen (second-line for moderate symptoms)
- See Vaginal Estrogen
- Does not require systemic Progesterone (in intact Uterus) if used <1 year
- Low dose Topical Estrogen (e.g. Vagifem, Estring, Estrace or Premarin vaginal cream)
- Reduces risk of Recurrent Urinary Tract Infection
- Suckling (2006) Cochrane Database Syst Rev (4): CD001500 [PubMed]
- Systemic Estrogens (third-line for refractory symptoms, especially Vasomotor Symptoms of Menopause)
- See Vasomotor Symptoms of Menopause
- Precautions
- Do not use Unopposed Estrogen with intact Uterus (requires concurrent Progesterone)
- Avoid systemic Estrogens for isolated, localized vaginal symptoms
- Continuous Estrogen Replacement
- Sequential Estrogen Replacement
- Transdermal Estrogen Replacement
- Higher dose Topical Estrogen (e.g. FemRing)
- Requires Progesterone (in intact Uterus), unlike low dose Topical Estrogens
X. Management: Refractory Symptoms (or unable to use Estrogens)
- Intravaginal Prasterone (Intrarosa, synthetic DHEA or Dehydroepiandrosterone)
- Vaginal Dehydroepiadrosterone that increases epithelial thickness and decreases Dyspareunia
- Indicated in Dyspareunia and moderate to severe Vulvovaginal Atrophy
- Although marketed as non-Estrogen, it is DHEA which converts to Estrogens and androgens in vaginal tissue
- Expensive (>$200/month)
-
Osphena (Ospemifene)
- Selective Estrogen receptor modifier (SERM) with Vaginal Estrogenic effect (unlike Raloxifene and Tamoxifen)
- FDA-approved for severe Dyspareunia
- Risk of venous thrombosis and Hot Flashes (similar to Raloxifene and Tamoxifen)
- Expensive (> $200/month) with limited indications beyond other measures
- Dose: 60 mg once daily with food
- (2013) Prescr Lett 20(6):33
- Fractional Carbon-Dioxide Laser Therapy
- Results in microabrasions that promote increased Blood Flow and thicken vaginal tissue
- Decreases Dyspareunia
- Similar efficacy to Vaginal Estrogens, but not FDA approved and risk of burns and scarring